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HealthPartners

Coverage criteria policies

Blood factor products

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required from HealthPartners Pharmacy Administration by all network providers for the administration of Hemlibra.

Prior authorization is required from HealthPartners Pharmacy Administration for network providers such as clinics and home infusion therapy (HIT) providers billing factor products on the medical benefit.

Prior authorization is not required when administering most factor products in an emergency room, urgent care facility, or preoperatively for outpatient surgery.

Except in the case of Hemlibra, prior authorization is not required for patients self-administering factor products. Self-infusion of prophylactic blood products is standard of care. All prescriptions must be filled by a preferred network pharmacy in order to receive benefit coverage.

Please see the Specialty Drug List for preferred network pharmacies.

Coverage

Self-Administered Blood Factor Products (excluding Hemlibra)

Products are covered without prior authorization under the pharmacy benefit.

Professionally-Administered Blood Factor Products (excluding Hemlibra)

  1. Prior authorization is required to verify the medical necessity of ongoing professional infusion assistance and dispensing of factor products by the clinic or home infusion therapy provider. Documentation that provides the reason for medical necessity must be submitted by the prescriber.
  2. When medically necessary, home infusion therapy (HIT) services are covered when all components below are provided:
    1. Intravenous (IV) administration of drugs to an individual in their home or an infusion suite; and,
    2. Nursing care, in the home, by a registered nurse; and,
    3. Appropriate HCPCS drug codes and report the NDC information for each drug in Loop 2410-Drug Identification.
      (Note: home nursing visits lasting up to 2 hours should use CPT code 99601. To report more than 2 hours, use 99602. Since the per diem “S” codes exclude nursing visits, if the nurse goes to the patient’s home to provide general nursing care/continuous administration of therapy (e.g., blood draw, wound care), the correct code to use is an “S” code. HCPC per diem “S” codes include charges for administrative services, professional pharmacy services, care coordination services, and all necessary supplies and equipment.)

Hemlibra

  1. Patient is diagnosed with hemophilia A (congenital factor VIII deficiency); and,
  2. Hemlibra is prescribed and managed by a specialist from a hemophilia treatment center; and,
  3. Patient is self-injecting Hemlibra and filling through a preferred network pharmacy. Professional administration is generally not considered medically necessary. Requests for professional administration require a provider statement of medical necessity and will be reviewed on a case-by-case basis. If professional administration is authorized, coverage requires the components in the Professionally-Administered section above; and,
  4. Prescribed within the FDA approved regimen.

Authorizations will be provided for one year.

Reauthorizations will be provided annually with documentation that the patient has been seen within the last 12 months at the hemophilia treatment center and the medication is effective. If approved for professional administration, then documentation of continued need for professional administration is required.

Definitions

Blood factor products include clotting factors used for hemophilia and related clotting disorders.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Drug Codes

Code

Description

Preparation

NDC Codes

J7175

Injection, Factor X, (Human), 1IU

Coagadex

64208775201

64208775301

J7178

Injection, human fibrinogen concentrate, 1 mg

RiaSTAP

63833089151

63833089190

J7179

Injection, Von Willebrand factor (recombinant), (Vonvendi), 1IU VWF:RCo

Vonvendi

00944755302

00944755102

J7180

Injection, factor XIII (antihemophilic factor, human), 1 IU

Corifact

63833051802

J7181

Injection, factor XIII A-subunit, (recombinant), per IU

Tretten

00169701301

J7182

Injection, factor VIII, (antihemophilic factor, recombinant),(Novoeight), per IU

Novoeight

00169781001

00169781501

00169782001

00169782501

00169783001

00169785001

J7183

Injection, von Willebrand factor complex (human), Wilate, 1 IU vWf:RCO

Wilate

67467018201

67467018202

68982018202

68982018201

J7185

Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha),per IU

Xyntha

58394001201

58394001202

58394001301

58394001302

58394001401

58394001402

58394001501

58394001502

58394001603

58394002203

58394002303

58394002403

58394002503

J7186

Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII IU

Alphanate

68516460302

68516460702

68516460402

68516460802

68516460101

68516460501

68516460201

68516460601

68516460902

68516461002

68516461101

68516461201

68516461302

68516461402

68516461502

J7187

Injection, Von Willebrand factor complex (Humate-P), per IU, vWF:RCO

Humate-P

63833061502

63833061602

63833061702

J7188

Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per IU

Obizur

00944500101

00944500105

00944500110

J7189

Factor VIIa (antihemophilic factor, recombinant), per 1 microgram

NovoSeven RT

00169720101

00169720201

00169720501

00169720801

J7190

Factor VIII (antihemophilic factor [human]), per IU

Hemofil M

00944394402

00944394602

00944394002

0094439420200944293101

00944293201

00944293001

00944293301

Koate-DVI

76125067250

76125067351

76125025020

76125066730

76125066750

76125066830

76125025620

76125067351

Monoclate-P

00053763302

00053763402

J7192

Factor VIII (antihemophilic factor, recombinant) per IU, NOS

Advate

00944292102*

00944292202*

00944292302*

00944292402*

00944294110*

00944294210*

00944294310*

00944294410*

00944294510*

00944294610*

00944294810*

00944296410*

00944296510*

00944304510*

00944304610*

00944304710*

00944305102*

00944305202*

00944305302*

00944305402*

Helixate FS

00053813102

00053813202

00053813302

00053813402

00053813502

Kogenate FS

00026378550

00026378555

00026378660

00026378665

00026378220

00026378225

00026378770

00026378775

00026378330

00026378335

00026379550

00026379660

00026379220

00026379770

00026379330

Recombinate

00944284110

00944284210

00944284310

00944284410

00944284510

J7193

Factor IX (antihemophilic factor, purified, non-recombinant) per IU

AlphaNine

68516360102

68516360202

68516360302

68516360402

68516360502

68516360602

68516360702

68516360802

68516360902

Mononine

00053623302

J7194

Factor IX complex, per IU

Bebulin

64193044502

Profilnine / Profilinine SD

68516320101

68516320202

68516320302

68516320401

68516320502

68516320602

68516320701

68516320801

68516320902

J7195

Factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified

BeneFIX

58394063303

58394063403

58394063503

58394063603

58394063703

Ixinity

53270027005

53270027105

53270027106

53270027205

53270027206

70504028205

70504028305

70504028405

70504028506

70504028606

70504028705

70504028805

70504028905

J7198

Anti-inhibitor, per IU

Feiba

64193022302

64193022502

64193042302

64193042402

64193042502

64193042602

C9399

J7199

-Unclassified drugs or biologicals

-Hemophilia clotting factor, not otherwise classified

Jivi

00026394225

00026394425

00026394625

00026394825

J7203 (effective 1/1/2019)

C9468 (use before 1/1/2019)

-Hemophilia clotting factor, not otherwise classified

-Injection, factor ix (antihemophilic factor, recombinant), glycopegylated, Rebinyn, 1 i.u.

Rebinyn

00169790101

00169790201

00169790501

00169791111

00169792211

00169795511

J7200

Injection, factor IX (antihemophilic factor recombinant), Ribuxis, per IU

Ribuxis

00944302602

00944302802

00944303002

00944303202

00944303402

J7201

Injection, factor IX, Fc fusion protein (recombinant), per IU

Alprolix

64406091101

64406092201

64406093301

64406094401

64406096601

64406097701

J7202

Injection, factor IX (recombinant), albumin fusion protein

Idelvion

69911086402

69911086502

69911086602

69911086702

69911086902

J7205

Injection, factor VIII, Fc fusion (recombinant), per IU

Eloctate

64406048308

64406048408

64406048508

64406048608

64406048708

64406048808

64406048908

64406080101

64406080201

64406080301

64406080401

64406080501

64406080601

64406080701

64406080801

64406080901

64406081001

71104080301

71104080501

71104080901

J7207

Injection, factor VIII, (antihemophillic factor, recombinant), pegylated, 1 IU

Adynovate

00944425202

00944425402

00944425602

00944425802

00944462201

00944462301

00944462401

00944462501

00944462601

00944462602

00944462701

00944462702

00944462801

00944462802

J7209

Injection, factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 IU

Nuwiq

68982013901

68982014001

68982014101

68982014201

68982014301

68982014401

68982014501

68982014601

68982014701

68982014801

68982014901

68982015001

68982015101

68982015201

J7210

Injection, factor VIII, (antihemophilic factor, recombinant)

Afstyla

69911047402

69911047502

69911047602

69911047702

69911047802

69911048002

69911048102

J7211

Injection, factor VIII, (antihemophilic factor, recombinant)

Kovaltry

00026382425

00026382650

00026382125

00026382850

00026382225

Q9995 (use before 1/1/2019)

J7170 (effective 1/1/2019)

Injection, emicizumab-kxwh, 0.5 mg

Hemlibra

50242092001

50242092101

50242092201

50242092301

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

Available upon request.

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Policy activity

  • 10/03/2014 - Date of origin
  • 01/01/2019 - Effective date
Review date
  • 08/2018
Revision date
  • 11/05/2018

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