- Step Therapy Applies
- Prior Authorization: Hemophilia A (Factor VIII):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Hemophilia A or B with Inhibitor:
PA Applies
- Hemophilia A (Factor VIII):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Dosing Limit(s): N/A
Diagnosis Type(s): 1 of Mild;Moderate;Severe
Diagnosis Treatments: 1 of Bleeding episodes;Routine propylaxis
Treatment Center Required: Yes
Hemophilia A or B with Inhibitor:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Dosing Limit(s): N/A
Diagnosis Type(s): Unspecified
Diagnosis Treatments: Routine propylaxis
Treatment Center Required: No
Dosing Limits Exist: No
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