Hemophilia / Bleeding Disorder Medication Prior Authorization Form Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
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
from form header
used for dosing and severity assessment
form asks whether dose calculated using ABW or IBW
Indicate if member underwent immune tolerance induction and outcome (success/failed)
Form also asks if member is a candidate for prophylactic therapy and if a management strategy is in place
Form requests drug name, strength, dose, directions, type of therapy, and failure documentation
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 |
Provider Submission Requirements and Actions
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
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
- Indicate candidacy for prophylactic therapy and provide supporting documentation
One Form Per Medication
Submit one fully completed form for each medication requested. Ensure member demographics, provider information (including physician name, NPI/Tax ID, address), medication information (name, strength, dose, directions, type of therapy, quantity, refills, shipping preference), and signature/date are included.
- Complete ALL information on the form; print/type legibly in blue or black ink
- Prescribing physician should complete the form in most cases
- Include physician address as required for notification
Payment and Eligibility Notice
Payment is subject to member eligibility at the time of claim; an authorization or approval does not guarantee payment.
- Authorization only indicates medical review approval and is not a guarantee of payment or coverage
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
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.