Factor VIII Products
EVICORE-MEDICAL_DRUG-F1F4B621
Covers FDA‑approved Factor VIII products for Hemophilia A (on‑demand, perioperative, and routine prophylaxis) and only Alphanate, Humate‑P, and Koate‑DVI for von Willebrand disease (including perioperative/surgical use when desmopressin is ineffective/contraindicated); non‑FDA uses are excluded. Requires FDA‑indicated diagnosis, prescribing by or consultation with a hemophilia specialist, documented inhibitor screening (no inhibitor, <5 BU/mL, or ≥5 BU/mL only if used as part of ITI), product‑specific age/prior‑treatment limits (e.g., Jivi ≥12 years and previously treated), weight‑based dosing documentation, IV administration, and approvals are for up to 12 months.
"Hemophilia A (congenital factor VIII deficiency) — On-demand treatment and control of bleeding episodes (Advate, Adynovate, Afstyla, Altuviiio, Eloctate, Esperoct, Jivi, Kogenate FS, Kovaltry, Novo..."