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Medical Injectables Program Update Reminder: Hemophilia Drugs to be Included

As a reminder, effective August 15, 2019, as part of the Medical Injectables Program (MIP), Magellan Rx Managements℠ (MRxM) will conduct medical necessity and appropriateness review (MNAR) for hemophilia drugs.

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 to review the clinical criteria and guidelines related to medical injectables (including hemophilia products).

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
If you don’t already have a username and password, you can obtain them by

  • Visiting
  • 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 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 1-888-656-6805.

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.

Beginning for services on and after August 15, 2019, the hemophilia drugs below will be included as part of our Medical Injectables Program (MIP) administered by Magellan Rx Management℠.

Brand Name Generic Name HCPCS
Advate factor viii J7192
Adynovate factor viii J7207
Afstyla factor viii J7210
Alphanate factor viii/vwf complex J7186
Alphanine SD factor ix J7193
Alprolix factor ix J7201
Bebulin factor ix J7194
BeneFIX factor ix J7195
Coagadex factor x J7175
Corifact factor xiii J7180
Eloctate factor viii J7205
Feiba NF anti-inhibitor coagulant complex J7198
Feiba VF anti-inhibitor coagulant complex J7198
Helixate FS factor viii J7192
Hemlibra emicizumab-kxwh J7170
Hemofil M factor viii J7190
Humate-P factor viii/vwf complex J7187
Idelvion factor ix J7202
Ixinity factor ix J7195
Koate DVI factor viii J7190
Kogenate FS factor viii J7192
Kovaltry factor viii J7211
Monoclate-P factor viii J7190
Mononine factor ix J7193
Novoeight factor viii J7182
Novoseven RT factor viia J7189
Nuwiq factor viii J7209
Obizur factor viii J7188
Profilnine SD factor ix J7194
Rebinyn factor ix J7203
Recombinate factor viii J7192
Rixubis factor ix J7200
Tretten coagulation factor xiiia – subunit J7181
Vonvendi von willebrand factor J7179
Wilate factor viii/vwf complex J7183
Xyntha factor viii J7185
Jivi factor viii J7199

Review the full list of injectable medications that require MNAR as part of the MIP, or learn more about our 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 Management℠ 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.

Published on: July 29, 2019, 07:56 a.m. ET
Last updated on: April 27, 2021, 23:11 p.m. ET