CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hemophilia Product Prior Authorization Form

Form and instructions to request prior authorization for a broad list of hemophilia-related products for members of Neighborhood Health Plan of Rhode Island; used by prescribers, pharmacies, and providers to submit clinical, demographic, and utilization information required for authorization.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHemophilia Product Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form in its entirety and fax all relevant progress notes, bleeding diaries, and lab results to 1-844-639-7906.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+products listed on the form

Multiplediagnoses options

Fax & phonesubmission channels

Includedinventory & dosing fields

Authorization Criteria

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Authorization criteria inputs

Form collects clinical and administrative information used to evaluate medical necessity for hemophilia-related products.

ALL of the following

Patient demographics (name, height, weight)
Member identification and insurance information
Prescriber information and contact details (including NPI, phone, fax)
Rendering provider/dispensing pharmacy information (name, NPI, NABP, contact, phone, fax)
Name of treating facility and facility contact information
Primary diagnosis with ICD-10 code (options include Congenital Hemophilia A, Acquired Hemophilia A, Hemophilia B, von Willebrand Disease, Congenital Factor XIII deficiency, Hereditary Factor X deficiency, Congenital Factor VII deficiency, Glanzmann's Thrombasthenia)
Product name (selected from list of covered hemophilia-related products)
Treatment status: treatment-naive or treatment-experienced; if previously on a different product, specify product and reason for switching
Severity of disease (factor level): Mild (6%–25%), Moderate (1%–5%), Severe (<1%)
Dose requested: Dose (IU), Number of doses requested, Total dose requested (IU); dosing instructions
Place and type of use (check all that apply): home infusion, prophylaxis, episodic, outpatient HTC, outpatient hospital, provider's office, surgical prophylaxis, dental procedure, acute bleeding episode, self-administration; include dates of procedure when applicable
Inventory on hand: total number of doses on hand; total units on hand (IU); date verified
Bleeding history: number and location of bleeds in the past 12 months; for acute bleeding episodes include location/type of bleed, start and end dates, severity, and number/amount of doses used
Laboratory and testing results: baseline factor level, date of factor level, desired (target) factor level; documentation of inhibitor testing (e.g., Bethesda assay) and whether results are attached
Inhibitor and prior therapies: presence of inhibitors; history of immune tolerance induction (ITI) with dates, duration, and response; platelet transfusion or desmopressin trial information when applicable
Pharmacokinetics (PK) testing: whether PK was performed and whether PK results are attached
Administrative: indicate if request is retrospective
Attachments: relevant progress notes, bleeding diaries, lab results (faxed as instructed)

Diagnosis, Inventory, and Dosing Details

Diagnosis codingICD-10

	ICD 10 Code
	Congenital Hemophilia A (Congenital Factor VIII Deficiency)
	Acquired Hemophilia A (Acquired 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

Inventory and dose reporting

Total number of doses on handTotal Number of Doses on Hand (reported on form)

Total units on handTotal Units on Hand (IU) (reported on form)

Total dose requestedTotal Dose Requested (IU) (reported on form)

Primary diagnoses covered on form

Congenital Hemophilia ACongenital Hemophilia A (Congenital Factor VIII Deficiency)

Acquired Hemophilia AAcquired Hemophilia A (Acquired Factor VIII Deficiency)

Hemophilia BHemophilia B (Congenital Factor IX Deficiency)

Other inherited/coagulation disordersvon Willebrand Disease; Congenital Factor XIII Deficiency; Congenital Factor XIII A-subunit Deficiency; Hereditary Factor X Deficiency; Congenital Factor VII Deficiency; Glanzmann's Thrombasthenia

Required clinical tests and prior therapies

Inhibitor testingDoes the patient have inhibitors to factor products? If yes, are documentation of inhibitor tests attached (e.g., Bethesda inhibitor assay)?

Immune Tolerance Induction (ITI)Has the patient previously received ITI? If yes, provide date, duration of trial and patient response.

Pharmacokinetic (PK) testingWas a PK test performed? If so, are PK testing results attached?

Platelet transfusion trialFor Glanzmann's Thrombasthenia, has the patient tried platelet transfusions? If yes, provide date and response.

Desmopressin trialFor von Willebrand Disease, has the patient tried desmopressin? If yes/no and contraindications, provide details and reason if contraindicated.

Submission and Provider Requirements

Prior Authorization

Submission instructions

Please complete the form in its entirety and include relevant progress notes and/or bleeding diaries. Fax all lab results to 1-844-639-7906 or call 401-427-8200 for assistance.

Complete form in its entirety
Include relevant progress notes and/or bleeding diaries
Fax all lab results to 1-844-639-7906
Phone inquiries: 401-427-8200

Documentation Required

Provider information required

Provide prescriber information and rendering provider (dispensing pharmacy) details including names, NPI, contact phone and fax numbers for both the prescriber and the dispensing pharmacy.

Prescriber: Prescriber name, contact name, contact phone #, NPI, fax #, address (city, state, zip)
Rendering provider (dispensing pharmacy): Pharmacy name, NPI, NABP, contact name, phone #, fax #

Documentation Required

Acute bleed documentation

For acute bleeding episodes, document the location and type of bleed, start and end dates, severity (minor/moderate/major), and the number, dose (IU), and total amount used (IU).

Location of bleed
Type of bleed
Start and end dates of bleed
Severity: Minor / Moderate / Major
Number of doses used, dose (IU), and total amount used (IU)

Prior Authorization

Treatment and utilization details

Indicate treatment status (treatment-naive or treatment-experienced), any prior product use and reason for switching, dosing details, place of administration, and whether the request is retrospective.

Treatment status: Treatment-naive or Treatment-experienced
If previously on a different factor product, specify which product and reason for switching
Dose (IU), number of doses requested, total dose requested (IU), and dosing instructions
Place of administration (e.g., home infusion, HTC, outpatient hospital, provider's office), and indicate if retrospective request

Clinical Definitions and Related Items

Primary diagnoses covered on form

Congenital Hemophilia ACongenital Hemophilia A (Congenital Factor VIII Deficiency)

Acquired Hemophilia AAcquired Hemophilia A (Acquired Factor VIII Deficiency)

Hemophilia BHemophilia B (Congenital Factor IX Deficiency)

Related inherited/coagulation disordersvon Willebrand Disease; Congenital Factor XIII Deficiency; Congenital Factor XIII A-subunit Deficiency; Hereditary Factor X Deficiency; Congenital Factor VII Deficiency; Glanzmann's Thrombasthenia

Required clinical tests and prior therapies

Inhibitor testingDoes the patient have inhibitors to factor products? If yes, are documentation of inhibitor tests attached (e.g., Bethesda inhibitor assay)?

Immune Tolerance Induction (ITI)Has the patient previously received ITI? If yes, provide date, duration of trial and patient response.

Pharmacokinetic (PK) testingWas a PK test performed? If so, are PK testing results attached?

Platelet transfusion trialFor Glanzmann's Thrombasthenia, has the patient tried platelet transfusions? If yes, provide date and response.

Desmopressin trialFor von Willebrand Disease, has the patient tried desmopressin and is there any contraindication? Provide details.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHemophilia Product Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form in its entirety and fax all relevant progress notes, bleeding diaries, and lab results to 1-844-639-7906.

SourceLink

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