Clinical Criteria

This coverage policy provides benefits for medications used to treat Hemophilia A, von Willebrand Disease, and Factor IX deficiency in Hemophilia B, provided they are deemed medically necessary and meet specific clinical indications. Key requirements include confirming the appropriate diagnosis through clinical documentation, with potential prior authorization necessary for treatment. Important limitations specify that coverage is not available for patients without a confirmed diagnosis and may involve frequency restrictions on medication administration.

"Medications listed are indicated for specific clinical uses as per associated drug documents."

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