Hemophilia Drug Policies - A Pilot Program for PEEHIP Members Only

Effective February 1, 2019, Blue Cross and Blue Shield of Alabama will implement a pilot program for members with hemophilia covered under Public Education Employee Health Insurance (PEEHIP). This program applies only to PEEHIP members with contract prefix EDU, group number 14000.

As part of this program:

  • Hemophilia factor replacement products will require prior authorization according to the medical policies listed below.
  • All hemophilia factor replacement products will be required to be dispensed through Option Care Specialty Pharmacy only.
  • Prior to each dispense of hemophilia factor replacement products, a dose authorization will be required to ensure appropriate assay management, inventory management, and patient engagement is being provided. Option Care will work with members to complete information required for this authorization.

Fax completed Prior Authorization Request Form to 1-866-606-6021.

Fax prescriptions for hemophilia factor replacement products to Option Care at 1-205-982-9408.

For general program information, call 1-401-344-1021.

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, Hexilate FS, 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