Last Review Date: 06/06/2022

Date of Origin: 12/16/2014

Dates Reviewed: 12/2014, 04/2015, 05/2015, 09/2015, 12/2015, 03/2016, 06/2016, 12/2016, 06/2017, 09/2017, 11/2017, 11/2018, 03/2019, 10/2019, 02/2020, 06/2021, 03/2022, 06/2022

1. Length of Authorization

Coverage is provided for 3 months and may be renewed thereafter, unless otherwise specified*.

Note: The cumulative amount of medication the patient has on-hand will be taken into account for authorizations. Up to 5 ‘on-hand’ doses for the treatment of acute bleeding episodes will be permitted at the time of the authorization request.

* Initial and renewal authorization periods may vary by specific covered indication

2. Dosing Limits

A. Quantity Limit (max daily dose) [NDC Unit]:

• Vonvendi 450-850 units: 82 vials per 90-day supply
• Vonvendi 900-1700 units: 41 vials per 90-day supply

B. Max Units (per dose and over time) [HCPCS Unit]:

• 36,800 billable units per 90 day supply

3. Initial Approval Criteria ^1-3

Coverage is provided in the following conditions:

• Patient is at least 18 years of age; AND

Von Willebrand Disease (vWD) † Ф

• Diagnosis of von Willebrand disease has been confirmed by blood coagulation and von Willebrand factor testing; AND

• Used for the treatment of spontaneous and trauma-induced bleeding episodes in at least one of the following:

• Patient has severe vWD
• Patient has mild or moderate vWD and the use of desmopressin is known or suspected to be ineffective or contraindicated
• Used for perioperative management of bleeding (Note: Authorizations valid for 1 month); OR

• Used for routine prophylaxis to reduce the frequency of bleeding episodes; AND

• Patient has severe Type 3 vWD and is receiving on-demand therapy

† FDA Approved Indication(s); ‡ Compendia recommended Indication(s); Ф Orphan Drug

4. Dispensing Requirements for Rendering Providers (Hemophilia Management Program)

• Prescriptions cannot be filled without an expressed need from the patient, caregiver or prescribing practitioner. Auto-filling is not allowed.
• Monthly, rendering provider must submit for authorization of dispensing quantity before delivering factor product. Information submitted must include:
  • • Original prescription information, requested amount to be dispensed, vial sizes available to be ordered from the manufacturer, and patient clinical history (including patient product inventory and bleed history)
    • Factor dose should not exceed +1% of the prescribed dose and a maximum of three vials may be dispensed per dose. If unable to provide factor dosing within the required threshold, below the required threshold, the lowest possible dose able to be achieved above +1% should be dispensed. Prescribed dose should not be increased to meet assay management requirements.
• The cumulative amount of medication(s) the patient has on-hand should be taken into account when dispensing factor product. Patients should not have more than 5 extra doses on-hand for the treatment of acute bleeding episodes.
• Dispensing requirements for renderings providers are a part of the hemophilia management program. This information is not meant to replace clinical decision making when initiating or modifying medication therapy and should only be used as a guide.

5. Renewal Criteria ^1-3

          Coverage may be renewed based upon the following criteria:

• Patient continues to meet the indication-specific relevant criteria identified in section III; AND
• Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: symptoms of allergic-anaphylactic reactions (anaphylaxis, dyspnea, rash, etc.), thromboembolic events (thromboembolism, pulmonary embolism), development of neutralizing antibodies (inhibitors), etc.; AND
• Any increases in dose must be supported by an acceptable clinical rationale (i.e. weight gain, half-life study results, increase in breakthrough bleeding when patient is fully adherent to therapy, etc.); AND
• The cumulative amount of medication(s) the patient has on-hand will be taken into account when authorizing. The authorization will allow up to 5 doses on-hand for the treatment of acute bleeding episodes as needed for the duration of the authorization; AND

Treatment of acute bleeding episodes/Treatment of spontaneous and trauma-induced bleeding

episodes/On-demand treatment of bleeding episodes

• Renewals will be approved for a 6 month authorization period

Routine prophylaxis to reduce the frequency of bleeding episodes

• Renewals will be approved for a 12 month authorization period; AND
• Patient has demonstrated a beneficial response to therapy (i.e., the frequency of bleeding episodes has decreased from pre-treatment baseline)

6. Dosage/Administration ^1-3

7. Billing Code/Availability Information

HCPCS Code & NDC(s):

8. References

1. Vonvendi [package insert]. Lexington, MA; Baxalta US Inc.; January 2022. Accessed April 2022.
2. MASAC Recommendations Concerning Products Licensed For The Treatment Of Hemophilia And Other Bleeding Disorders. Revised August 2020 National Hemophilia Foundation. MASAC Document #163; August 2020. Available at: http://www.hemophilia.org. Accessed April 2022.
3. Guidelines for the Management of Hemophilia. 3rd Edition. World Federation of Hemophilia 2020. Available at: https://www1.wfh.org/publications/files/pdf-1863.pdf.  Accessed April 2022.
4. Annual Review of Factor Replacement Products. Oklahoma Health Care Authority Review Board. Updated April 2016. Access April 2022.
5. Graham A1, Jaworski K. Pharmacokinetic analysis of anti-hemophilic factor in the obese patient. Haemophilia. 2014 Mar;20(2):226-9.
6. Croteau SE1, Neufeld EJ. Transition considerations for extended half-life factor products. Haemophilia. 2015 May;21(3):285-8.
7. Mingot-Castellano, et al. Application of Pharmacokinetics Programs in Optimization of Haemostatic Treatment in Severe Hemophilia a Patients: Changes in Consumption, Clinical Outcomes and Quality of Life. Blood. 2014 December; 124 (21).
8. MASAC Recommendation Concerning Prophylaxis. 2016 National Hemophilia Foundation.  MASAC Document #241; February 2016. Available at: http://www.hemophilia.org. Accessed April 2022.
9. MASAC Recommendations Regarding the Treatment of von Willebrand Disease. MASAC Document #266; March 2021. Available at: 266.pdf (hemophilia.org). Accessed April 2022.
10. Connell NT, Flood VH, Brignardello-Petersen R, et al. ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease. Blood Advances, Volume 5, Issue 1, 2021, Pages 301-325, https://doi.org/10.1182/bloodadvances.2020003264.
11. Franchini M, Seidizadeh, Mannucci P, et al. Prophylactic management of patients with von Willebrand disease. Ther Adv Hematol. 2021; 12: 20406207211064064. Published online 2021 Dec 22. doi: 10.1177/20406207211064064
12. First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Hemophilia Clotting Factors (A56482). Centers for Medicare & Medicaid Services Inc. Updated on 02/05/2021 with effective date 01/01/2021. Accessed April 2022.
13. Palmetto GBA. Local Coverage Article: Billing and Coding: Guidance for Anti-Inhibitor Coagulant Complex (AICC) National Coverage Determination (NCD) 110.3 (A56065). Centers for Medicare & Medicaid Services Inc. Updated on 02/01/2021 with effective date 01/01/2021. Accessed April 2022.
14. Novitas Solutions, Inc. Local Coverage Article: Billing and Coding: Hemophilia Factor Products (A56433). Centers for Medicare & Medicaid Services Inc. Updated on 05/07/2021 with effective date 04/08/2021. Accessed April 2022.

Appendix 1 – Covered Diagnosis Codes

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications may be covered at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCA/LCD):