CurrentHighmark Blueshield NenyPolicy N/A

Hemophilia / Bleeding Disorder Medication Prior Authorization Form Coverage Criteria

Covers prior authorization documentation and clinical criteria required for authorization of hemophilia and bleeding-disorder therapies for Highmark Blue Shield members; affects prescribing providers requesting coverage for factor products and related medications.

Policy Summary

PayerHighmark Blueshield Neny

PolicyHemophilia / Bleeding Disorder Medication Prior Authorization Form Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a separate, fully completed prior authorization form with required clinical documentation and provider signature via fax to 1-866-240-8123 or mail to SPECARE, 120 Fifth Avenue, Pittsburgh, PA 15222.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

severe <1%Severe baseline factor

moderate 1%-5%Moderate baseline factor

mild 5-40%Mild baseline factor

1-866-240-8123Fax

SPECARE Pittsburgh

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Coverage and Medical Necessity Criteria

Clinical documentation required for authorization

Authorization is assessed using completed clinical criteria fields when ALL of the following are documented

Required documentation: Diagnosis code and description must be provided

from form header

Factor level: Baseline factor level (%) must be provided and categorized (mild/moderate/severe)mild 5-40%; moderate 1-5%; severe <1%

used for dosing and severity assessment

Weight: Member actual body weight (ABW) and date measured must be provided for dose calculations

form asks whether dose calculated using ABW or IBW

Inhibitor status: Past history of inhibitor development and current inhibitor presence with Bethesda units must be documented

Indicate if member underwent immune tolerance induction and outcome (success/failed)

Therapy intent: Type of therapy must be specified (On-Demand/Prophylaxis/Perioperative)

Form also asks if member is a candidate for prophylactic therapy and if a management strategy is in place

Prior therapies: Alternatives tried and documentation of failure of therapy should be provided (up to two prior drugs)

Form requests drug name, strength, dose, directions, type of therapy, and failure documentation

Reauthorization/Response: For reauthorization, documentation that member is stable on therapy and any bleeding episodes during therapy are documented (occurrence and type)

Form asks whether condition is stable and whether bleeding episodes occurred with details

The form itself does not list additional or separate coverage criteria beyond the clinical fields it requests. Authorization decisions are based on the completion of the form’s required clinical information (diagnosis, baseline factor level, weight, inhibitor history, therapy intent, prior therapies and supporting documentation).

The form contains no explicit statements enumerating conditions that are "not medically necessary." It does, however, state that the provider certifies the information is true and that payment is subject to member eligibility and that authorization does not guarantee payment.

Coding and Clinical Definitions

No codes listed on formmixed

No codes listed

Baseline factor level categories — mild/moderate/severe definitions

Mild baseline factor level5%–40% baseline factor level

Moderate baseline factor level1%–5% baseline factor level

Severe baseline factor level<1% baseline factor level

Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Submission Requirements

Prior authorization is required. Submit the completed prior authorization form with all supporting clinical documentation, including diagnosis, baseline factor level, inhibitor status (current or past), Bethesda units if applicable, body weight and date measured, and any relevant treatment history.

Fax completed form and all clinical documentation to 1-866-240-8123
Or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222

Documentation Required

Alternatives Tried and Failure Documentation

The form collects prior therapies tried, details (drug name, strength, dose, directions), type of therapy, and documentation of failure. It also asks whether the member is a candidate for prophylactic therapy, whether a management strategy is in place, and requests reauthorization stability and bleed documentation when applicable.

List each prior medication trial with dose, dates, and reason for failure

Background and Purpose

This form is intended to support prior authorization decisions for treatment of bleeding disorders by capturing the clinical details used to assess medical necessity and dosing. Required information includes diagnosis and description, disease severity and baseline factor level, member weight and measurement date for dose calculations, inhibitor history and Bethesda measurements, type/intent of therapy (on‑demand, prophylaxis, perioperative), prior therapies and failure documentation, and the medical rationale/treatment plan.

Definitions and Clinical Measures

Baseline factor level categories — mild (5-40%), moderate (1%-5%), severe (<1%)

Mild5%–40%

Moderate1%–5%

Severe<1%

Bethesda Units (BU) — inhibitor quantification measure

Bethesda Units (BU)Laboratory measure used to quantify inhibitor titer (documented on form as 'Bethesda Units (BU)')

Inhibitor presenceForm requests whether an inhibitor is currently present and, if yes, the BU value

Historical inhibitor data