Prior Authorization Criteria for Luspatercept-aamt (Reblozyl) Effective September 1, 2020

Note:   Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 1, 2020, prior authorization will be required for Luspatercept-aamt (Reblozyl) (procedure code J0896) for Texas Medicaid.

Luspatercept-aamt (Reblozyl) is a benefit for clients who are 18 years of age and older, and is approved for treatment of the following:

• Anemia in adult clients with beta thalassemia requiring red blood cell (RBC) transfusions
• Anemia failing an erythropoiesis stimulating agent and requiring two or more red blood cell units over eight weeks in adult clients with low to intermediate-risk myelodysplastic syndrome with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T)

Luspatercept-aamt (Reblozyl) must be prescribed by, or in consultation with, a hematologist.

Prior Authorization Requirements

Prior authorization requests for procedure code J0896 must be submitted with a Special Medical Prior Authorization (SMPA) Request Form.

Documentation of the client’s dosage, administration schedule, number of doses to be administered during the prior authorization period, the requested units per dose, and the dosage calculation must be submitted in Section C of the Special Medical Prior Authorization (SMPA) Request Form under Statement of Medical Necessity.

The Special Medical Prior Authorization (SMPA) Request Form must be completed, signed, and dated by the prescribing provider. The Special Medical Prior Authorization (SMPA) Form will not be accepted beyond 90 days from the date of the prescribing provider’s signature.

The completed Special Medical Prior Authorization (SMPA) Request Form must be maintained by the prescribing provider in the client's medical record and is subject to retrospective review.

Initial Requests

For initial prior authorization requests, the client must be 18 years of age or older and meet the following criteria:

• Client who has anemia with beta thalassemia requiring regular RBC transfusions:
  • The client must have a diagnosis of beta thalassemia.
  • The client required regular RBC transfusions of six or more units within the previous 24 weeks and has had no transfusion-free period for 35 days or longer during the review period.
• Client who has anemia failing an erythropoiesis stimulating agent:
  • The client must have a diagnosis of myelodysplastic syndrome classified as low to intermediate risk disease.
  • The client must require RBC transfusions of two or more units over a period of eight weeks.
  • The client must be ineligible or must have failed prior erythropoietin stimulating agent treatment.
  • Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy, the client must meet the initial age and diagnosis criteria, in addition to the following requirements:

• Client who has anemia with beta thalassemia requiring regular RBC transfusions:
  • The client had a positive response/hematological improvement demonstrated by a reduction in RBC transfusion as indicated by the prescribing physician.
  • The client previously received treatment with luspatercept-aamt (Reblozyl) without complications.
• Client who has anemia failing an erythropoiesis stimulating agent:
  • The client had a positive response demonstrated by RBC transfusion independence during any consecutive eight-week period or a decrease in transfusion requirement as indicated by the prescribing physician.
  • The client previously received treatment with luspatercept-aamt (Reblozyl) without complications.

For more information, call the TMHP Contact Center at 800-925-9126.