Hemophilia Drug Policies

Drug policies are based on:

  • information in FDA-approved package inserts (and black box warnings, alerts or other information disseminated by the FDA, as applicable);
  • research of current medical and pharmacy literature; and/or,
  • review of common medical practices in the treatment and diagnosis of disease.

Final and draft policies are published on this site. Draft policies are available for provider comment for 45 days from the posting date on the document. We encourage practicing physicians to provide input.

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.

Please use the Search function above to locate specific drug policy information.

Pharmacy Policies Disclaimer

Pharmacy drug policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Policy # Policy Title Print View
PH-2000 Hemophilia Products – Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)
PH-2001 Hemophilia Products – Anti-Inhibitor Coagulant Complex: Feiba NF/Feiba VF
PH-2002 Hemophilia Products – Factor IX: Alphanine SD, Alprolix, Bebulin, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
PH-2003 Hemophilia Products – Factor VIIa: Novoseven RT
PH-2004 Hemophilia Products – Factor VIII: Advate, Adynovate, Afstyla, Eloctate, Hemofil M, Koate DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha, and Jivi
PH-2005 Hemophilia Products – Factor X: Coagadex
PH-2006 Hemophilia Products – Factor XIII: Corifact
PH-2007 Hemophilia Products – Coagulation Factor XIII A-subunit: Tretten
PH-2008 Hemophilia Products – von Willebrand Factor: Vonvendi
PH-2009 Hemophilia Products – Factor VIII/VWF Complex: Alphanate, Humate-P, Wilate