Hemophilia Product Prior Authorization Form - Coverage Criteria
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This form governs prior authorization data collection for coverage of hemophilia and related coagulation factor products for Medica members; it affects prescribing providers, dispensing pharmacies, and reviewers assessing medical necessity.
No material clinical or coverage changes in this revision.
Coverage Criteria and Documentation Requirements
Authorization data required to establish medical necessity
Covered when ALL of the following documentation elements are provided as applicable:
Chunks: 1-4
Chunk: 7
Chunk: 7
Chunks: 7,8
Chunk: 8
Chunk: 9
Chunk: 8
The form does not specify explicit coverage exclusions; however, it requires documentation of prior standard therapies or documented contraindications where applicable. For example, the form requests prior trials of desmopressin for von Willebrand disease and platelet transfusions for Glanzmann's Thrombasthenia or a documented contraindication to those therapies when a trial was not performed. Providers should attach dates and responses to prior therapy trials when applicable to support medical necessity.
The form must be completed in its entirety and faxed with relevant progress notes, bleeding diaries, and all laboratory results as instructed. The document does not enumerate specific not medically necessary conditions; however, incomplete or missing required documentation may result in denial of the prior authorization. Ensure all required fields and attachments are provided to avoid processing delays.
Diagnosis and Coding Details
| Congenital Hemophilia A | Congenital Factor VIII Deficiency |
| Acquired Hemophilia A | Aquired Factor VIII Deficiency |
| Hemophilia B | Congenital Factor IX Deficiency |
| von Willebrand Disease | |
| Congenital Factor XIII Deficiency | |
| Congenital Factor XIII A-subunit Deficiency | |
| Hereditary Factor X Deficiency | |
| Congenital Factor VII Deficiency | |
| Glanzmann's Thrombasthenia | |
| ICD 10 Code | ICD 10 Code (space provided on form for specific code) |
Submission Instructions and Required Provider Steps
Form submission requirement
Submit the completed Hemophilia Product Prior Authorization Form along with all requested clinical documentation. Fax materials to 1-888-656-0841 or call 1-800-424-7892. All lab results and attachments must be included with the initial submission to avoid delay.
- Hemophilia Product Prior Authorization Form (fully completed)
- Progress notes and bleeding diaries
- All relevant lab results (including baseline factor levels and dates)
- Inhibitor testing results (e.g., Bethesda assay) when applicable
- Pharmacokinetic (PK) test results, if performed
- Documentation of prior factor products and reasons for switching
- Immune Tolerance Induction (ITI) history and response, if applicable
- For Glanzmann's Thrombasthenia: documentation of platelet transfusion trial and response
- For von Willebrand Disease: documentation of desmopressin trial or contraindication explanation
Prior therapy documentation
Provide clear documentation of prior therapies or trials when requested. Include dates, doses, responses, and reasons therapy was discontinued or switched. This is required for evaluation of medical necessity.
- Record of prior factor products used, dates and reason for switching
- Desmopressin trial documentation for VWD patients (or documented contraindication and reason)
- Platelet transfusion trial documentation for Glanzmann's Thrombasthenia (dates and response)
- ITI treatment history (dates, duration, and patient response)
Required attachments
Required attachments must be included with the prior authorization submission. Failure to attach the items below may result in denial or delay of the request.
- Progress notes and bleeding diaries covering relevant timeframe
- All lab results including baseline factor level and date
- Inhibitor testing results (e.g., Bethesda assay) when indicated
- PK testing results, if available
- Completed dosing information: dose (IU), number of doses requested, total IU, and dosing instructions
- Documentation of treatment status (treatment-naïve vs experienced) and prior product use
- Procedure dates for surgical or dental prophylaxis requests
- Place of administration and type of use (episodic, prophylaxis, acute bleed)
Incomplete submission risk
Incomplete submissions — missing the completed form or any supporting documentation listed above — risk denial or processing delays. Ensure all checkboxes, clinical fields (e.g., severity, factor levels), and attachments are provided on initial submission.
- Fax complete packet to 1-888-656-0841 or call 1-800-424-7892 for questions
- All lab results must be faxed with the submission
- Retrospective requests should clearly indicate retrospective status and include full clinical justification
Information Required for Initial Authorization or New Product Starts
Initial authorization documentation — information requested to support initiation or new product authorization
Information requested to support initiation or new product authorization includes:
Chunks: 7,8
Chunk: 8
Chunk: 7
Chunk: 7
Chunk: 8
Chunk: 9
Step Therapy / Prior Trial Requirements
| Requirement | Documentation to provide |
|---|---|
| Prior therapy trial for von Willebrand Disease (VWD) | |
| Documentation of desmopressin trial or statement of contraindication (include reason if contraindicated) | |
| Prior therapy trial for Glanzmann's Thrombasthenia | |
| Documentation of platelet transfusion trial and patient response (dates and outcomes) | |
| Prior factor product use (minimally treated patients) | |
| For patients with < 50 exposure days, frequency of planned inhibitor testing and attached testing schedule/results | |
| Immune Tolerance Induction (ITI) history | |
| If ITI performed: dates, duration, and patient response |
Quantity and Dosing Information
Place of Administration
Specify place of administration
Indicate the place of administration on the form by selecting one of the provided options (home infusion, outpatient hemophilia treatment center, outpatient hospital, provider's office, or self-administration).
Disease Severity Definitions
Background and Purpose
This Hemophilia Product Prior Authorization Form is used to document the member’s diagnosis, disease severity, bleeding history, and laboratory confirmation needed to support coverage of factor and related hemostatic products. The form collects severity of disease (Mild: 6%–25%, Moderate: 1%–5%, Severe: <1%), baseline and target factor levels with dates, inhibitor status, number and location of bleeds over the prior 12 months, intended type of use (episodic, prophylaxis, acute bleed, dental/surgical prophylaxis), and the place of administration (home infusion, HTC, outpatient hospital, or office).
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