At the spring Senate Budget Subcommittee Hearing chaired by Richard Pan, M.D. Medi-Cal Director Mari Cantwell told the Subcommittee that Hemlibra would now be treated as a “carve out” drug under Medi-Cal Managed Care. Below is the specific information outlined by DHCS on that administrative policy:
Hemlibra, a non-blood factor treatment for Hemophilia, is “carved out” from Medi-Cal Managed Care for CCS clients. This means that:
1. For all patients under age 21 (CCS Eligible) in Whole Child Model counties, any requests made to the MCPs for Hemlibra should be redirected to the ISCD CCS office for adjudication. 2. Hemlibra SARs and all necessary medical documentation can be sent via the e-SAR process (preferred method) or manually faxed to a dedicated fax for specialty prescriptions: 916-440- 5768. All Hemlibra SARs will be promptly adjudicated by the ISCD CCS office.
3. In Non CCS Whole Child Model counties, providers/pharmacies with Hemlibra requests should also be submitting SARs to the ISCD CCS office. If requests are sent to the County CCS offices for Hemlibra or other specialty prescription or treatments, the County CCS offices know to forward those requests to the ISCD CCS Specialty Prescription and Treatment e-fax number at 916-440-5768.
4. TARs are not required for Hemlibra for CCS patients and should not be sent to CAASD – all adjudication for Specialty Drugs, including Hemlibra for CCS patients, is done by the ISCD CCS office and requests should be sent as SARs not TARs. The use of TARs are restricted to patients that have aged out of the CCS program and are in straight Medi-Cal. These are adjudicated by CAASD.
5. SARs are required for Hemlibra for GHPP patients and should be sent to CAASD for adjudication via CMSNET, fax at 916-440-5318 or emailed to GHPP@dhcs.ca.gov. For GHPP SAR Authorization inquiries, please send an email to email@example.com.
Are there any plans to move Hemlibra reimbursement in with factor payments? For 340B institutions, the current reimbursement of $13.20 does not even cover ancillary supplies much less shipping and staff time.
HCC does not get involved in specific payments for drugs. Currently, Hemlibra is not classified as a blood factor. It is up to the drug manufacturer to negotiate drug pricing with the State of California.