CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

PEEHIP Hemophilia Product Prior Authorization Form and Documentation Checklist

Prior authorization form and documentation checklist for hemophilia and related clotting factor products for members covered by Blue Cross and Blue Shield of Alabama (PEEHIP). Affects prescribers, dispensing pharmacies, and treating facilities requesting coverage for listed products.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyPEEHIP Hemophilia Product Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form and all supporting documentation, including progress notes and inhibitor testing results, to 1-866-606-6021.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+listed hemophilia products on form

12clinical/administrative sections on the form

Fax 1fax number for submission

Coverage and Submission Criteria

Required submission criteria

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Basic administrative and clinical information: Completed patient, provider, and pharmacy information; insurance details; indication (select diagnosis); and ICD-10 code.

see chunks 8

Clinical severity and testing: Severity classification (Mild/Moderate/Severe), baseline factor level with date, desired target factor level, and inhibitor testing status with results (e.g., Bethesda assay).

see chunks 8 and 9

Type of use: Request indicates one or more of: episodic use, prophylaxis, acute bleeding episode, dental or surgical prophylaxis (include procedure dates), place of administration, and dosing instructions/quantities requested.

see chunk 8

Prior therapies or contraindications when applicable: For von Willebrand disease: documentation of desmopressin trial or documented contraindication; for Glanzmann's Thrombasthenia: documentation of platelet transfusion trial and response; for patients who received prior factor products: history of prior product and reason for switch; for minimally treated patients (< 50 exposure days) include plan/frequency for inhibitor testing.< 50 exposure days

see chunks 8 and 9

Immune tolerance and PK information: Documentation of prior Immune Tolerance Induction (ITI) if performed (dates, duration, response) and pharmacokinetic (PK) testing results when available.

see chunk 9

Retrospective or utilization reconciliation details: If retrospective request or for utilization reconciliation, provide number and dates of doses used, number of doses/units on hand, dose (IU), and total amount used.

see chunk 8 and 10

Acute bleed details (when applicable): For acute bleeding episodes provide location and type of bleed (minor/moderate/major), start and end dates, number of doses used, dose (IU), and total amount used (IU).

see chunk 10

Diagnosis and Coding Details

Diagnosis Codes (ICD-10)ICD-10

ICD-10

ICD-10 code field provided for primary diagnosis (specific codes not listed on form)

Exposure days

Exposure days threshold< 50 exposure days for 'minimally treated' patients

ImplicationMinimally treated patients (< 50 exposure days) require a plan for more frequent inhibitor testing; form asks: 'how often will inhibitor testing be performed?'

Context for prior product switchApplies when patient previously received a different factor product; used to guide monitoring frequency

Provider Responsibilities and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for the hemophilia products listed on the Hemophilia Product Prior Authorization Form. Complete and submit the form in its entirety and fax the form and all required attachments to 1-866-606-6021. All lab results must be faxed in with the request.

Affected products: Helixate FS; Alphanate; Hemlibra; Wilate; Kogenate FS; BeneFIX; Idelvion; Novoeight; Ixinity; Vonvendi; Recombinate; Rixubis; Afstyla; Xyntha; Alprolix; Adynovate; Coagadex; Eloctate; Corifact; Feiba; Feiba NF; NovoSeven; RT Hemofil M; Koate-DVI; Monoclate-P; Nuwiq; Advate; Obizur; Humate-P; AlphaNine SD; Mononine; Bebulin; Kovaltry; Profilnine; Rebinyn; Tretten
Fax number for submission: 1-866-606-6021

Documentation Required

Prior Therapy Documentation Required

Document prior therapy trials when applicable. For von Willebrand disease (VWD) include documentation of a trial of desmopressin or a contraindication to desmopressin with the reason. For Glanzmann's thrombasthenia include documentation of platelet transfusion trials and response. For patients previously treated with a different factor product, indicate prior product and reason for switching. Include dates and responses for prior immune tolerance induction (ITI) if applicable.

VWD: desmopressin trial documentation or documented contraindication and reason
Glanzmann's Thrombasthenia: platelet transfusion trial dates and response
Prior factor product: name, dates, and reason for switching
Previous ITI: dates, duration, and patient response

Documentation Required

Required Documentation for Submission

Required documentation must accompany the prior authorization form. Incomplete requests risk denial or return-to-provider for additional information.

Completed Hemophilia Product Prior Authorization Form (all fields)
Patient demographics and provider/pharmacy contact information
Progress notes and/or bleeding diaries documenting number and location of bleeds in the past 12 months
Relevant laboratory results (baseline and most recent factor levels, dates, desired target levels)
Inhibitor testing results (e.g., Bethesda assay) and documentation of frequency of inhibitor testing for minimally treated patients (<50 exposure days)
Pharmacokinetic (PK) test results, if performed
Dosing details: dose (IU), number of doses requested, total dose requested, and dosing instructions
Procedure information for surgical or dental prophylaxis (type and date of procedure) and place of administration
For retrospective requests, indicate retrospective status on the form

Denial Risk

Missing Documentation — Denial Risk

Requests may be denied or returned to the provider if the form is incomplete or required attachments are missing.

Missing or incomplete prior authorization form
Absence of progress notes or bleeding diaries
Missing lab results or inhibitor testing documentation (e.g., Bethesda assay)
Missing prior therapy documentation (desmopressin trial for VWD, platelet transfusion for Glanzmann's, prior product trials, ITI details)

Policy Form Background

The form collects detailed clinical data for congenital and acquired bleeding disorders, including diagnoses such as Congenital Hemophilia A/B, Acquired Hemophilia A, von Willebrand disease, factor deficiencies, and Glanzmann's Thrombasthenia. It requests information on disease severity and history (e.g., prior bleeds, number of spontaneous joint bleeds), laboratory results (factor levels, inhibitor testing such as the Bethesda assay), prior treatments and trials (desmopressin for VWD, platelet transfusions for Glanzmann's), treatment status (naïve versus experienced), and additional details for acute bleeding or procedural prophylaxis.

Definitions and Clinical Categories

Severity of Disease

Mild6% to 25% factor level

Moderate1% to 5% factor level

Severe< 1% factor level

Inhibitor testing

Type of testTesting for neutralizing antibodies to factor products (e.g., Bethesda inhibitor assay)

Documentation requestedAttach inhibitor test results to the request form (asks: 'are documentations of inhibitor tests attached?')

Immune tolerance historyIndicate prior Immune Tolerance Induction (ITI) status with date, duration, and patient response

Minimally treated monitoringFor patients with < 50 exposure days, form requests plan for frequency of inhibitor testing