Medicare AdvantagePrior AuthMedium impact
Factor VIII Replacement Products (Hemophilia A) (Revised)
Humana·KY · Hematology, Pediatrics, Internal Medicine·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
This is a revised Factor VIII replacement product prior authorization policy for Hemophilia A treatment, effective January 20, 2017, with most recent updates on December 17, 2025. The policy covers 18 Factor VIII products across two main indications: routine bleeding prophylaxis and on-demand bleeding control/perioperative management. All Factor VIII product requests now require prior authorization approval with specific clinical criteria documentation for Medicaid/Medicare Kentucky members.
Action Required
By December 31, 2025: Billing and clinical teams must update prior authorization submission workflows for all Factor VIII replacement products (Advate, Adynovate, Afstyla, Altuviiio, Eloctate, Esperoct, Hemofil-M, Jivi, Koate, Kogenate FS, Kovaltry, Novoeight, Nuwiq, Recombinate, Xyntha, Xyntha Solofuse, Hemofil M variants). Verify that all PA requests for these HCPCS codes include documentation of: (1) congenital hemophilia A diagnosis (Factor VIII deficiency), and (2) clinical indication (either routine prophylaxis to reduce bleeding frequency OR on-demand/perioperative bleeding control). Update EMR templates and billing software to enforce these two required criteria. Providers must document the specific indication on all PA requests. Claims submitted without documented clinical criteria meeting these requirements will be denied. Note: Koate and Hemofil-M are excluded from routine bleeding prophylaxis coverage. Jivi is restricted to patients age 12+ and previously treated patients only - verify age and treatment history before submitting PA.