Hemophilia specialty pharmacy / factor replacement prior authorization form
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This document is a provider-completed prior authorization and dispensing form used to request clotting factor products and related dispensing for patients with bleeding disorders; it affects prescribers, specialty pharmacies, and Blue Cross Blue Shield - Alabama reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Authorization Requirements
Authorization prerequisites
Covered when ALL of the following are met
Required for processing
Includes signature attesting assay closest to prescribed dose when applicable
Bleeding diary fields encouraged
All information must be faxed to 1-888-656-0841
The form does not list any explicit clinical exclusions. Coverage determinations are based on review of the fully completed specialty pharmacy/prescription form together with any supporting clinical documentation submitted (for example, progress notes or bleeding diaries). Ensure all required fields are completed and supporting documentation is provided to allow processing.
There are no conditions or situations marked on the form itself as Not Medically Necessary. Decisions about medical necessity will be made by the reviewer based on the information supplied on the completed form and accompanying documentation.
Billing and Coding Information
Provider Submission, Documentation, and Dispensing Requirements
Submit completed form and fax to 1-888-656-0841
Prior authorization requests must include the completed specialty pharmacy/prescription form and all clinical and dispensing details faxed to Blue Cross Blue Shield - Alabama at 1-888-656-0841.
No step-therapy specified — include product and justification
This form does not impose a required step-therapy sequence; when requesting a specific product include the chosen product, dosing details, and any assay justification if applicable.
Include progress notes and bleeding diaries with bleed details
Attach the fully completed form plus relevant clinical documentation: progress notes and bleeding diaries that capture bleed dates, type (mild/moderate/severe), location, number of doses used, and total units (IU) used.
Provide patient and prescriber identifiers (including NPI)
Provide complete administrative identifiers on the form: patient name, date of birth, contract number, and prescriber information including name and National Provider Identifier (NPI).
Supply complete product, dose, vial strength, units, and assay info
Record full prescription and dispensing details on the form: product name, IU per dose, dosing frequency, total dose (IU) requested, total number of doses/units to dispense, vial strength, number of vials requested, assay availability, and place of administration.
Incomplete submissions may not be processed or may be denied
Failure to complete the form in its entirety or to provide the required progress notes and/or bleeding diaries may prevent the request from being processed or may result in denial.
Background and Scope
This form is the provider-completed prior authorization and dispensing request used to obtain clotting factor products for patients. It captures the intended type of use (such as Acute Bleeding Episode, Episodic, Prophylaxis, Dental Procedure, or Surgical Prophylaxis), specific prescription and dispensing details, and bleed event information (dates, severity, location, doses and total units used). The completed form and relevant progress notes or bleeding diaries must be faxed to 1-888-656-0841 for review and authorization.
Form Fields: Indications and Bleeding Severity
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