Update: Blood Factor Carve-In

Managed Care Policy & Planning Meeting

September 8, 2016

Blood Factor Carve–In

Factor products are currently carved out of the managed care benefit package. Blood factor products will be included in the managed care benefit package and premium rate. Carve–in date dependent on rate setting cycle (July 1, 2017).

Managed care enrollees receive factor products billed to FFS Medicaid by pharmacies or hemophilia clinics.

Summary of Data – Fourth Quarter 2016:

  • Pharmacy (NDC) claims: 149 managed care enrollees, $15.8 million
  • J–code claims: 94 managed care enrollees, $10.37 million

Unique members overall = 239

Carve–In principles – enrollees and providers:

  • Current managed care enrollees keep their current provider of blood factor for two years.
  • New managed care enrollees keep their current provider of blood factor for two years, to be re–evaluated in 2020.
  • Blood factor providers and plans are expected to provide patient specific care management, ensuring enrollees have appropriate and timely supplies of factor product and coordination with practitioners.
  • Standard of care and treatment of hemophilia is a continually changing field and should be driven by good clinical rationale and utilize an individualized plan of care.
  • All FDA approved products are covered.

Carve–in principles – rates and data:

  • Adjustment will be made to existing pharmacy premiums with regional and risk adjustments effective with the carve–in date.
  • A high cost pool will be established for plans with a disproportionate share of blood factor costs.
  • Medical premiums will be adjusted after the carve–in date, dependent on the utilization of factor through medical providers.
  • Member specific factor utilization data is on the Monthly FFS Pharmacy feed currently provided to plans.

Upcoming tasks

  • CMS notification
  • Stakeholder engagement
  • Rate setting
  • Plan readiness
  • Network and Contracting