By Counterforce Health Team in Hemlibra (emicizumab-kxwh) —

How to Get Hemlibra (Emicizumab-kxwh) Covered by Blue Cross Blue Shield in Georgia: Coding, Appeals, and Timeline Guide

Answer Box: Getting Hemlibra Covered by BCBS in Georgia

Blue Cross Blue Shield of Georgia (Anthem) requires prior authorization for Hemlibra (emicizumab-kxwh). Your fastest path to approval: 1) Gather complete hemophilia A documentation including Factor VIII inhibitor status, 2) Submit PA request through Availity or Anthem's provider portal using ICD-10 code D66 and HCPCS J7170, and 3) If denied, file internal appeal within plan deadlines. Georgia residents have external review rights through the state DOI within 60 days of final denial.

First step today: Contact your hematologist to compile bleeding history, inhibitor test results, and prior therapy failures for the PA submission.

Table of Contents

Understanding BCBS Coverage Requirements

Blue Cross Blue Shield of Georgia (operating as Anthem) classifies Hemlibra as a specialty medication requiring prior authorization. The drug is covered for patients with congenital hemophilia A, both with and without Factor VIII inhibitors, but only when specific clinical criteria are met.

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all patients Complete PA form via Availity/Anthem portal Anthem Provider News
Diagnosis Congenital hemophilia A ICD-10 code D66 with clinical confirmation Medical records
Inhibitor Status Must be documented Lab results showing presence/absence of Factor VIII inhibitors Laboratory reports
Prior Therapies Failed or inappropriate alternatives Documentation of inadequate response or contraindications Treatment history
Dosing Plan Weight-based subcutaneous regimen Loading and maintenance schedule Prescriber attestation

Essential Coding for Clean Claims

Getting the coding right from the start prevents delays and denials. Hemlibra billing differs depending on whether it's covered under medical or pharmacy benefits.

Medical Benefit Coding (Provider-Administered)

Primary codes you'll need:

  • ICD-10: D66 (Hereditary factor VIII deficiency)
  • HCPCS: J7170 (Injection, emicizumab-kxwh, 0.5 mg)
  • NDC: Match to vial strength (e.g., 50242-0920-01 for 30 mg/1 mL)

Billing unit calculation: Each 0.5 mg = 1 J7170 unit. For a 30 mg dose, you'd bill 60 units of J7170.

Tip: As of January 2024, add the JZ modifier when no drug is discarded from single-use vials to comply with CMS requirements.

Pharmacy Benefit Coding (Specialty Pharmacy)

When dispensed through specialty pharmacy, use the 11-digit NDC corresponding to the exact vial strength:

  • 50242-0927-01: 12 mg/0.4 mL
  • 50242-0920-01: 30 mg/1 mL
  • 50242-0921-01: 60 mg/0.4 mL
  • 50242-0922-01: 105 mg/0.7 mL
  • 50242-0923-01: 150 mg/1 mL
  • 50242-0930-01: 300 mg/2 mL

Documentation Requirements for Hemophilia A

Your medical records must clearly establish:

Diagnosis confirmation:

  • Family history of hemophilia A
  • Factor VIII activity level (severe <1%, moderate 1-5%, mild 5-40%)
  • Genetic testing results (if available)

Inhibitor status documentation:

  • Current inhibitor titer results
  • History of inhibitor development
  • Impact on previous Factor VIII replacement therapy

Treatment history:

  • Previous prophylaxis attempts with Factor VIII concentrates
  • Bleeding episodes despite treatment
  • Adverse reactions or contraindications to alternatives
  • Quality of life impact

Step-by-Step Prior Authorization Process

Step 1: Gather Required Documentation (Patient/Clinic)

Timeline: 1-2 days
What you need:

  • Complete medical history with bleeding episodes
  • Laboratory confirmation of hemophilia A diagnosis
  • Factor VIII inhibitor test results
  • Documentation of failed prior therapies
  • Weight-based dosing calculations

Step 2: Submit PA Request (Provider)

Timeline: Same day
How to submit: Through Availity or Anthem's provider portal
Required elements:

  • Completed prior authorization form
  • ICD-10 code D66
  • Intended HCPCS/NDC codes
  • Clinical justification letter
  • Supporting lab results and treatment history

Step 3: BCBS Review Process

Timeline: Up to 14 calendar days (expedited: 72 hours)
What happens: Medical review team evaluates clinical necessity against plan criteria
Possible outcomes: Approved, denied, or request for additional information

Step 4: If Additional Information Requested

Timeline: Respond within 14 days to avoid automatic denial
Common requests:

  • More detailed bleeding history
  • Additional inhibitor testing
  • Peer-to-peer consultation opportunity
Note: Request expedited review if delays could seriously jeopardize your health. BCBS must respond within 72 hours for urgent cases.

When Denials Happen: Georgia Appeal Rights

If your initial PA is denied, Georgia law provides robust appeal protections through multiple levels of review.

Internal Appeal Process

Timeline: Must be filed within plan deadlines (typically 180 days for commercial plans)
Decision timeframe: 30 days for pre-service, 60 days for post-service
How to file: Contact BCBS member services at the number on your card

What to include in your appeal:

  • Copy of original denial letter
  • Updated clinical documentation
  • Medical necessity letter from your hematologist
  • Peer-reviewed literature supporting Hemlibra use
  • Documentation of failed alternatives

Georgia External Review Process

If your internal appeal is denied, you have the right to an independent external review through the Georgia Department of Insurance.

Key deadlines:

  • 60 days from final internal denial to request external review
  • 72 hours or less for expedited urgent reviews
  • 30 business days for standard external review decisions

How to request:

  1. Contact Georgia DOI Consumer Services: (800) 656-2298
  2. Complete the Request for External Review form
  3. Submit supporting medical documentation
  4. Include copy of BCBS final denial letter

Who reviews: Independent physicians with relevant specialty board certification will evaluate your case against medical standards, not just plan policies.

Important: External review decisions are binding on BCBS and are free for Georgia consumers.

Common Pitfalls and How to Avoid Them

Coding Errors

Problem: Using wrong ICD-10 code (D68.311 for acquired vs. D66 for hereditary)
Fix: Verify diagnosis type and use D66 for congenital hemophilia A

Problem: Incorrect J7170 unit calculations
Fix: Remember 1 unit = 0.5 mg, so multiply total mg dose by 2

Documentation Gaps

Problem: Missing inhibitor status documentation
Fix: Include current inhibitor titer results, even if negative

Problem: Insufficient prior therapy documentation
Fix: Detail specific Factor VIII products tried, doses, duration, and reasons for inadequacy

Submission Issues

Problem: Using outdated PA forms or portals
Fix: Always verify current submission requirements through Anthem provider resources

Cost-Saving Resources

Even with insurance coverage, Hemlibra can involve significant out-of-pocket costs. Several programs can help:

Manufacturer Support

Genentech Patient Foundation: Provides financial assistance for eligible patients
Hemlibra Co-pay Program: May reduce monthly costs for commercially insured patients
Contact: Visit Genentech-Access.com for current programs

State and Federal Programs

Georgia Medicaid: May cover Hemlibra for eligible low-income patients
340B Drug Pricing Program: Reduces costs at qualifying healthcare facilities

Specialty Pharmacy Benefits

Many BCBS plans contract with specialty pharmacies that provide:

  • Coordination with manufacturer programs
  • Clinical support and monitoring
  • Home delivery and injection training

Counterforce Health helps patients and providers navigate the complex prior authorization process for specialty medications like Hemlibra. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with payer requirements. By turning insurance denials into strategic appeals, they help families get the medications they need while reducing the administrative burden on healthcare providers. Learn more at CounterforceHealth.org.

FAQ

How long does BCBS prior authorization take for Hemlibra in Georgia?

Standard PA decisions are made within 14 calendar days. Expedited reviews for urgent cases must be completed within 72 hours. You can request expedited review if delays would seriously jeopardize your health.

What if Hemlibra isn't on my BCBS formulary?

You can request a formulary exception with medical justification. Your provider must demonstrate that formulary alternatives are ineffective or inappropriate for your specific case. BCBS must respond within 72 hours of receiving complete documentation.

Can I get an emergency supply while waiting for approval?

Yes, BCBS may provide up to a 31-day emergency supply of Hemlibra while your formulary exception or appeal is being processed. Contact member services to request this coverage.

What happens if I move from another state to Georgia?

Your new Georgia BCBS plan may have different PA requirements than your previous insurer. Work with your new hematologist to submit fresh documentation that meets Georgia Anthem's specific criteria.

Does step therapy apply to Hemlibra?

Many BCBS plans require trying conventional Factor VIII prophylaxis before approving Hemlibra. However, step therapy can be overridden with documentation of medical necessity, such as Factor VIII inhibitor development or inadequate response to standard therapy.

How do I know if my appeal was successful?

BCBS will send written notification of all PA and appeal decisions. For external reviews, the Georgia DOI will issue a final decision letter. If approved, BCBS is legally required to cover the treatment.

What if I disagree with the external review decision?

External review decisions are final for the administrative process. Further disputes would need to be pursued through the court system, though this is rarely necessary for medically appropriate treatments.

Can I use Counterforce Health to help with my Hemlibra appeal?

Yes, Counterforce Health specializes in helping patients and providers create compelling appeals for specialty medications. Their platform can analyze your specific denial and generate targeted responses that address BCBS's exact concerns.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at (800) 656-2298.

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