Medical Injectables Program Update: Hemophilia Drugs to be Included
Effective August 15, 2019, as part of the Medical Injectables Program (MIP), Magellan Rx ManagementSM (MRxM) will conduct medical necessity and appropriateness review (MNAR) for hemophilia drugs.¹
Beginning for services on and after August 15, 2019, the hemophilia drugs listed in the table below will be included as part of our MIP administered by MRxM.
This program is designed to promote collaboration with providers to help ensure that patients are receiving the most appropriate dose of product based on each individual’s unique clinical situation. Additionally, there will be an added component of the review process to be completed by the rendering provider prior to dispensing hemophilia products to ensure appropriate assay management, inventory management, and patient engagement is being provided.
Access our Medical Policy Manual at HorizonBlue.com/MedicalPolicy to review the clinical criteria and guidelines related to medical injectables (including 10 hemophilia product-related medical policies to be implemented on August 15, 2019).
Submitting hemophilia MNAR requests for review
Obtaining a pre-service MNAR determination through MRxM will help expedite claims processing. If you fail to obtain a pre-service determination, your claims may be delayed or denied pending receipt of clinical information to establish medical necessity and appropriateness.
Submit MIP MNAR requests through MrxM’s secure website by visiting ih.magellanrx.com.
If you don’t already have a username and password, you can obtain them by:
- Visiting ih.magellanrx.com
- Clicking the Providers and Physicians icon
- Clicking New User Request Access (within the yellow Sign In section)
- Clicking Contact Us
- Completing the required fields and then clicking Send
The Hemophilia Case Review Form process
The rendering provider will be required to complete a Hemophilia Case Review Form available on HorizonBlue.com/MIP. This process helps to ensure impacted members receive the appropriate administration of medication and helps to track bleed history of patients on hemophilia medication.
This form should be completed prior to dispensing the first dose, and prior to each time additional doses are dispensed and must include:
- Original prescription information
- Requested amount to be dispensed including specific vial sizes
- Vial sizes available
- Patient clinical history (including patient product inventory and bleed history)
Completed Hemophilia Case Review Forms can be faxed to MRxM at 1-888-656-0841.
Based on the review of the Hemophilia Case Review Form, MRxM will send a Dose Recommendation Letter to the rendering provider. Please note that the Dose Recommendation Letter is not an approval letter and it does not replace the MNAR.
Hemophilia drugs to be included in the MIP
Beginning for services on and after August 15, 2019, the hemophilia drugs below (sorted by brand name) will be included as part of our MIP administered by MRxM.
|BRAND NAME||GENERIC NAME||HCPCS CODE|
|ALPHANATE||FACTOR VIII/VWF COMPLEX||J7186|
|ALPHANINE SD||FACTOR IX||J7193|
|FEIBA NF||ANTI-INHIBITOR COAGULANT COMPLEX||J7198|
|FEIBA VF||ANTI-INHIBITOR COAGULANT COMPLEX||J7198|
|HELIXATE FS||FACTOR VIII||J7192|
|HEMOFIL M||FACTOR VIII||J7190|
|HUMATE-P||FACTOR VIII/VWF COMPLEX||J7187|
|KOATE DVI||FACTOR VIII||J7190|
|KOGENATE FS||FACTOR VIII||J7192|
|NOVOSEVEN RT||FACTOR VIIA||J7189|
|PROFILNINE SD||FACTOR IX||J7194|
|TRETTEN||COAGULATION FACTOR XIIIA – SUBUNIT||J7181|
|VONVENDI||VON WILLEBRAND FACTOR||J7179|
|WILATE||FACTOR VIII/VWF COMPLEX||J7183|
Review the full list of injectable medications that require MNAR as part of the MIP.
If you have any questions, please contact your Network Specialist, Network Hospital Specialist or Ancillary Contracting Specialist.
¹ Medical necessity and appropriateness review is not required for injectable medications that are administered during an inpatient stay, or in an Emergency Room setting or Observation Room setting. For medical injectable services rendered in the patient’s home, call 1-855-243-3321 for participating Horizon Care@Home health care professionals to obtain pre-service determination.
Magellan Rx ManagementSM is a service mark of Magellan Health, Inc. Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of conduct medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey.