- Step Therapy: Hemophilia A (Factor VIII):
ST Single Brand
- Hemophilia A (Factor VIII):
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Hematologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Dosing Limit(s): Unspecified
Diagnosis Type(s): Unspecified
Diagnosis Treatments: Routine propylaxis
Treatment Center Required: No
Hemophilia A or B with Inhibitor:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Hematologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Dosing Limit(s): <= 3
Diagnosis Type(s): Unspecified
Diagnosis Treatments: 1 of Bleeding episodes;Routine propylaxis
Treatment Center Required: No
Dosing Limits Exist: No
- Prior Authorization: Hemophilia A (Factor VIII):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Hemophilia A or B with Inhibitor:
PA Applies
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