Luspatercept-aamt (Reblozyl) (CPB 0963, reviewed 2026-06-12)

By June 12, 2026: Billing team must implement precertification requirement for all Luspatercept-aamt claims by updating billing system rules to require prior authorization before claim submission. Update encounter forms and provider education materials with new criteria: (1) for beta thalassemia—verify patient age ≥18, pretreatment hemoglobin ≤11 g/dL, diagnosis confirmed by hemoglobin electrophoresis/HPLC or molecular testing, and ≥6 RBC units transfused in prior 24 weeks; (2) for MDS/MDS-MPN—verify age ≥18, disease risk category, hemoglobin ≤11 g/dL, and ≥2 RBC units per 8 weeks; (3) for myelofibrosis—follow compendial use guidelines. Verify prescriber specialty before approval (hematologist or specialist for thalassemia; hematologist or oncologist for MDS/MPN/myelofibrosis). Add hard stops in billing system to deny claims with excluded diagnoses (D56.0, D56.3, D56.8, D57.42, D57.431-D57.439, D57.44, D57.451-D57.459) or concurrent mitapivat use. Configure continuation of therapy re-authorization to require documentation of transfusion burden reduction and absence of unacceptable toxicity. Route all precertification requests to (866) 752-7021 or fax (888) 267-3277 per policy. Claims submitted without completed precertification will be denied.