CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Roctavian (valoctocogene roxaparvovec-rvox) IV gene therapy for severe hemophilia A

Policy governs coverage, authorization, dosing, monitoring, and billing for a single lifetime intravenous dose of Roctavian for Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members per listed medical necessity criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRoctavian (valoctocogene roxaparvovec-rvox) IV gene therapy for severe hemophilia A

Policy CodePolicy N/A

Change Typeclarified

Effective Date01/01/2024

Next Review Date

Key ActionSubmit medical records/chart notes documenting diagnosis, genetic/mutation testing, prior therapies, factor VIII activity, inhibitor testing results, AAV5 antibody test results, and infectious/hepatic status via PA web portal upload or fax; records will be reviewed at time of submission.

SourceLink

POLICY UPDATE CHANGES

Effective date and HCPCS effective date listed as 01/01/2024; J1412 HCPCS effective 01/01/2024 included.

1Lifetime Doses Allowed

44Max Vials per Dose (one-time)

D66Covered Diagnosis Code

Coverage Summary

Roctavian (valoctocogene roxaparvovec-rvox) is an AAV5-based gene therapy indicated for adults with severe hemophilia A who are AAV5 antibody negative. Coverage is provided with specific medical necessity criteria and is limited to a single lifetime intravenous dose. The policy scope includes Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members. Key safety concerns include liver enzyme elevations and infusion-related reactions among other adverse events.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.