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 review for 45 days from the posting date on the policy. 

Note: Coverage is subject to member's specific benefits. Group-specific policies will supersede these policies, when applicable. Always verify member eligibilty and benefits.

Use the navigation on the left or search function above to locate specific drug policy information.


Pharmacy drug policies provide a guide to coverage. Pharmacy policies are not intended to dictate to providers how to practice medicine. Providers 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, BeneFIX, Idelvion, Ixinity, Mononine, Profilnine, Rebinyn, and Rixubis
PH-0340 Hemophilia Products - Factor VIII Prior Authorization Program Summary
PH-0341 Hemophilia Products - Factor X: Coagadex
PH-0342 Hemophilia Products - Factor XIII: Corifact
PH-0343 Hemophilia Products – Factor VIIa: NovoSeven RT ™; Sevenfact
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)