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Clotting Factors: Noncapitated Service Added to Select Managed Care Plans

June 6, 2019

Effective retroactively for dates of service on or after December 1, 2017, emicizumab-kxwh (Hemlibra), a clotting factor disorder treatment, is a noncapitated service for Managed Care Plans (MCPs) except for the following Health Care Plans (HCPs):

  • Cal MediConnect
  • Program of All-Inclusive Care for the Elderly (PACE)
  • Senior Care Action Network (SCAN)

This drug is listed under the subheading “Blood Factors: Clotting Factor Disorder Treatments” in the Part 1 manual.

Providers billing for Emicizumab-kxwh drugs should follow billing instructions for noncapitated services (fee-for-service Medi-Cal or special programs) as specified in the Injections: Drugs E-H Policy section of the appropriate Part 2 manual.

Hemlibra is a covered pharmacy benefit for Medi-Cal beneficiaries with an approved Treatment Authorization Request (TAR).

Updated manual pages will be released in a future Medi-Cal Update.

In addition, information regarding retroactive billing and TAR adjudication will be released in a future Medi-Cal Update.