Hympavzi (marstacimab-hncq) prior authorization and coverage
Defines prior authorization criteria, dosing, renewal, billing codes, NDCs, covered diagnoses, and documentation requirements for marstacimab (Hympavzi) for routine prophylaxis of congenital Hemophilia A and B without inhibitors for commercial members of Medical Mutual - Ohio.
HCPCS code J7172 effective 07/01/2025 replaces prior codes C9304 and J3590 which were discontinued 07/01/2025.
Coverage Summary
coverage_stance: covered_with_criteria; scope_summary: Defines prior authorization criteria, dosing, renewal, billing codes, NDCs, covered diagnoses, and documentation requirements for marstacimab (Hympavzi) for routine prophylaxis of congenital Hemophilia A and B without inhibitors for commercial members of Medical Mutual - Ohio; effective date: 2024-12-31; status: CURRENT; brief dosing indication: Loading dose 300 mg (two 150 mg subcutaneous injections) followed by maintenance 150 mg weekly, with possible escalation to 300 mg weekly per criteria.