Medicare AdvantagePrior AuthMedium impact
Reblozyl® (luspatercept-aamt) (Revised)
Humana·SC, VA · Hematology, Oncology, Internal Medicine·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 2, 2026
Summary
This is a revised Reblozyl (luspatercept-aamt) prior authorization policy effective January 1, 2025, covering treatment of transfusion-dependent beta-thalassemia and MDS-associated anemia. The policy applies to Medicare and Medicaid (South Carolina and Virginia) with specific clinical criteria required for approval. Key updates include revised indications, updated exclusion criteria (S/B+ thalassemia, alpha thalassemia), and stricter MDS requirements including IPSS-R risk scoring and restrictions on ESA combination therapy.
Action Required
By December 31, 2024: Billing team must update prior authorization workflows in billing software to reflect new Reblozyl approval criteria for both beta-thalassemia and MDS indications. Create or update PA request templates to require: (1) For beta-thalassemia: diagnosis confirmation and exclusion of S/B+ and alpha thalassemia; (2) For MDS: IPSS-R risk score documentation, ring sideroblast status, EPO levels ≤500 mU/mL if RS-negative, ESA trial documentation (except VA Medicaid), and confirmation no concurrent ESA therapy. Front desk staff must ensure providers submit complete clinical documentation with PA requests to avoid denials. Verify member eligibility for SC/VA Medicaid or Medicare before processing. Update encounter templates to prompt providers for required clinical parameters. Non-compliance will result in claim denials for insufficient documentation or unmet clinical criteria.