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-0337 Hemophilia Products - Anti-Inhibitor Coagulant Complex: Feiba NF/Feiba VF
PH-0338 Hemophilia Products - Coagulation Factor XIII A-subunit: Tretten
PH-0339 Hemophilia Products - Factor IX: Alphanine SD, Alprolix, Bebulin, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
PH-0340 Hemophilia Products - Factor VIII: Advate, Adynovate, Afstyla, Eloctate, Hemofil M, Koate DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Xyntha, Jivi
PH-0341 Hemophilia Products - Factor X: Coagadex
PH-0342 Hemophilia Products - Factor XIII: Corifact
PH-0343 Hemophilia Products - Factor VIIa: Novoseven RT
PH-0344 Hemophilia Product - von Willebrand Factor: Vonvendi
PH-0345 Hemophilia Products - Factor VIII/VWF Complex: Alphanate, Humate-P, Wilate
PH-0349 Hemophilia Products - Anti-Inhibitor Antibody: Hemlibra (emicizumab-kxwh)