CurrentMedicaPolicy N/A

Hemophilia Product Prior Authorization Form - Coverage Criteria

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.

Policy Summary

PayerMedica

PolicyHemophilia Product Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed Hemophilia Product Prior Authorization Form with clinical information, dosing requested, and supporting labs/notes via fax or phone as provided on the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9document chunks

multiplecovered diagnoses listed

labs & historyclinical docs requested

Coverage Criteria and Documentation Requirements

Authorization data required to establish medical necessity

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required_fields: Completed patient, provider, and insurance information (demographics, prescriber, dispensing pharmacy, and insurance ID).

Chunks: 1-4

diagnosis_and_severity: Primary diagnosis selected from listed disorders and an ICD-10 code provided; severity of disease indicated (mild/moderate/severe).

Chunk: 7

treatment_intent_and_dosing: Product name, dose (IU), number of doses requested, total IU requested, dosing instructions, and type of use (episodic, prophylaxis, acute bleed, dental/surgical prophylaxis) provided; place of administration indicated.

Chunk: 7

laboratory_confirmation: Documentation of diagnosis by blood coagulation testing and baseline factor level with date and desired target factor level attached.

Chunks: 7,8

inhibitor_information: Inhibitor status provided and inhibitor test documentation attached if positive; prior ITI history and response provided if applicable.

Chunk: 8

bleeding_history: Number and location of bleeds in past 12 months and for acute episodes provide location, type, dates, doses used, and total amount used.

Chunk: 9

prior_therapy_trials: For VWD: desmopressin trial or documented contraindication; For Glanzmann's: platelet transfusion trial and response; document prior factor products and reason for switching.

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

Primary Diagnosis (ICD-10)ICD-10

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)

Exposure days threshold

Exposure days threshold< 50 exposure days

Field on formSeverity of Disease and treatment history requested to determine exposure days relevance

UseApplied to differentiate treatment-naïve vs treatment-experienced patients for authorization considerations

Submission Instructions and Required Provider Steps

Prior Authorization

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

Documentation Required

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)

Documentation Required

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)

Denial Risk

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:

baseline_labs: Baseline factor level, date of level, and desired target factor level; documentation of diagnosis by coagulation testing.

Chunks: 7,8

inhibitor_and_prior_trials: Inhibitor status and Bethesda assay results if positive; prior Immune Tolerance Induction (ITI) history with dates, duration, and response when applicable.

Chunk: 8

treatment_history_and_switching: History of prior factor products, whether patient was treatment-naïve or treatment-experienced, and reason for product switching if applicable.

Chunk: 7

dosing_and_site_of_care: Requested dose (IU), number of doses, total IU requested, dosing instructions, type of use (episodic, prophylaxis, acute bleed, dental/surgical/surgical prophylaxis) and place of administration indicated (home, HTC, outpatient hospital, office, self-administration).

Chunk: 7

pk_and_monitoring: If performed, pharmacokinetics (PK) test results attached and plan for inhibitor testing for minimally treated patients (< 50 exposure days) documented.< 50 exposure days

Chunk: 8

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

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

unspecified (product name provided on form) — dosing and IU required

Required dose detailsNumber of doses requested must be provided on the form

Required potency detailsTotal dose requested (IU) / Total units on hand (IU) must be provided

Supporting verificationDate verified for medication on hand should be recorded

Context fieldsDose (IU) and dosing instructions fields are present to support the requested quantity

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).

Policy Summary

PayerMedica

PolicyHemophilia Product Prior Authorization Form - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed Hemophilia Product Prior Authorization Form with clinical information, dosing requested, and supporting labs/notes via fax or phone as provided on the form.

SourceLink

On This Page

OpenPayer

Hemophilia Product Prior Authorization Form - Coverage Criteria

Coverage Criteria and Documentation Requirements

Diagnosis and Coding Details

Submission Instructions and Required Provider Steps

Information Required for Initial Authorization or New Product Starts

Step Therapy / Prior Trial Requirements

Quantity and Dosing Information

Place of Administration

Disease Severity Definitions

Background and Purpose