Medica Hemophilia Program

These policies apply Medica's Commercial, Individual & Family, Minnesota Health Care Programs and Medica Health Plan Solutions plans. Medica's Medicare Advantage, Dual Solutions and AccessAbility Solutions Enhanced plans are excluded from Hemophilia Prior Authorization. For Mayo Medical Plan, please reference plan specific clinical guidelines.

 

Hemophilia Products Prior Authorization Form

Hemophilia Case Review Form

 

Anti-Inhibitor Coagulant Complex (Feiba NF/Feiba VF) 

Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)

Factor VIIa (Novoseven RT)

Factor VIII (Advate, Adynovate, Afstyla, Eloctate, Esperoct, Hemofil M, Hexilate FS, Jivi, Koate DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha)

Factor IX  (Alphanine SD, Alprolix, Bebulin, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, Rixubis)

Factor X (Coagadex)

Factor XIII (Corifact)

Coagulation Factor XIII A-subunit (Tretten)

von Willebrand Factor (Vonvendi)

Factor VIII/VWF Complex  (Alphanate, Humate-P, Wilate)

 

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