CurrentCignaPolicy v020126

Hympavzi (marstacimab-hncq) prior authorization

Prior authorization form and requirements for Hympavzi (marstacimab-hncq) for patients with hemophilia A or B, used by providers requesting coverage through Cigna. Affects prescribers, infusion sites, and pharmacies submitting requests.

Policy Summary

PayerCigna

PolicyHympavzi (marstacimab-hncq) prior authorization

Policy CodePolicy v020126

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the Cigna prior authorization form (fax 855-840-1678 or submit online) and attach required clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

855-840-1678fax

800-882-4462urgent phone

Accredopreferred specialty pharmacy

Coverage Criteria for Hympavzi (marstacimab-hncq)

Initial and continuation therapy criteria

Coverage consideration when the following documentation and clinical conditions are met

Primary conditions

Diagnosis evidence: Checked diagnosis box for Hemophilia A WITHOUT inhibitors OR Hemophilia B WITHOUT inhibitors OR other indication.
Chunk 9.
Purpose of therapy: Prophylactic use to prevent or reduce the frequency of bleeding episodes is indicated.
Chunk 9.
Specialist involvement: Medication prescribed by or in consultation with a hemophilia specialist.
Chunk 9.

Policy Summary

PayerCigna

PolicyHympavzi (marstacimab-hncq) prior authorization

Policy CodePolicy v020126

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the Cigna prior authorization form (fax 855-840-1678 or submit online) and attach required clinical documentation.

SourceLink

On This Page

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Documentation for initial therapy (Hemophilia A or B)

Baseline factor level: Baseline (without replacement) Factor VIII or Factor IX level ≤ 2% documented.≤ 2%
Chunks 10,12.
Prior factor therapy and inhibitors: Documentation whether patient has received Factor VIII/IX therapy previously; if yes, provide inhibitor titer testing performed within the past 30 days and, when positive, report inhibitor titer ≥ 1.0 Bethesda units/mL.Inhibitor titer ≥ 1.0 BU/mL when present
Chunks 10,11,12,13.

Requests must include the specific clinical documentation requested on the prior authorization form. For initial therapy this includes documentation of baseline (without replacement) Factor VIII or Factor IX level ≤ 2% when applicable and, if the patient has received prior factor therapy, recent inhibitor titer testing per the form. For inhibitor testing, documentation should show a titer ≥ 1.0 Bethesda units/mL when reported positive. Attach supporting materials such as chart notes, laboratory results, medical test results, claims records, and prescription receipts; failure to attach required documentation may result in the request being considered incomplete and may lead to denial.

Billing and Clinical Codes

Requested drug billing codemixed

J-code

J-Code placeholder for Hympavzi (to be specified on form)

Baseline Factor level — ≤ 2% (Factor VIII or Factor IX)

Baseline factor thresholdBaseline (without replacement) Factor VIII or Factor IX level ≤ 2%

Applies toPatients with Hemophilia A or Hemophilia B being considered for initial therapy with Hympavzi

Documentation requiredMedical documentation (e.g., chart notes, lab results) demonstrating baseline factor level ≤ 2% must be attached or request may be denied

Inhibitor titer — ≥ 1.0 Bethesda units/mL

Inhibitor titer thresholdPositive test for Factor VIII or Factor IX inhibitors ≥ 1.0 Bethesda units/mL

When requiredWhen patient has prior exposure to Factor VIII or Factor IX and inhibitor testing is applicable (per form prompts)

Documentation requiredAttach specific inhibitor test results (medical documentation) or the request may be denied

Provider Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization required for Hympavzi (marstacimab-hncq). Complete and fax the Cigna form or submit online; indicate new start vs continuation as applicable.

Submit via fax using the Cigna prior authorization form or online at CoverMyMeds/SureScripts in your EHR.
Indicate whether this is a new start or continuation of therapy.

Note

Site of Care Consideration

Infusion should occur in the least intensive medically appropriate setting when applicable. Consider alternate infusion sites (e.g., physician office, home infusion, specialty infusion center) and coordinate with a Specialty Care Options Case Manager to determine suitability for re-direction.

Document the planned site of care on the request (home, physician office, hospital outpatient, other).
If the patient is a candidate for home infusion or an alternate infusion site, note this and provide medical necessity rationale if redirected from a higher-intensity setting.

Documentation Required

Required Supporting Documentation

Attach supporting medical documentation with the request. Examples include chart notes, laboratory results (baseline Factor VIII/IX levels), inhibitor titer testing results, medical test results, claims records, and prescription receipts to substantiate the clinical indication and prior treatments.

If initial therapy for Hemophilia A or B: include baseline (without replacement therapy) Factor VIII or Factor IX level documentation when applicable.
If prior Factor VIII/IX therapy or inhibitors: include recent inhibitor titer testing (within 30 days) and any positive Bethesda unit results.
Include documentation of therapeutic response if this is a continuation of therapy.

Denial Risk

Documentation-Dependent Denial Risk

Requests may be denied if required medical documentation is not provided. Failure to attach requested baseline factor levels, inhibitor titer testing, chart notes, lab results, or other supporting records may result in denial.

Missing baseline Factor VIII/IX levels for initial therapy requests.
Missing inhibitor titer test results when prior inhibitor or testing is indicated.
Insufficient documentation of prior therapies or clinical response for continuation requests.

Key Definitions

Prophylactic use definition — routine prophylaxis to prevent or reduce frequency of bleeding episodes

DefinitionRoutine prophylaxis: use of Hympavzi to prevent or reduce the frequency of bleeding episodes

Concurrent therapy queryForm asks whether Hympavzi will be used concurrently with other subcutaneous hemostatic agents (Alhemo, Hemlibra, Qfitlia)

Specialist involvementForm asks whether the medication is prescribed by or in consultation with a hemophilia specialist

Definition of moderately severe to severe hemophilia — baseline Factor VIII or Factor IX level ≤ 2% (without replacement therapy)

Severity thresholdModerately severe to severe hemophilia defined as baseline (without replacement) Factor VIII or Factor IX level ≤ 2%

Applies to initial therapyForm requests documentation of this baseline level when assessing eligibility for initial Hympavzi therapy

Documentation instructionAttach medical documentation (chart notes, laboratory results, test results) to support the baseline level claim

Background

Hympavzi (marstacimab-hncq) is requested for use in patients with Hemophilia A or Hemophilia B, with or without inhibitors, for routine prophylaxis to prevent or reduce bleeding episodes. The prior authorization form asks whether the medication will be used concurrently with other subcutaneous hemostatic agents and whether the prescribing clinician is a hemophilia specialist. For initial therapy the form requires evidence of moderately severe to severe disease (baseline Factor VIII or IX ≤ 2%) and documentation about prior factor therapy and inhibitor testing when applicable.

OpenPayer