J0896 — Injection, luspatercept-aamt, 0.25 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For beta thalassemia: medical record documentation demonstrating diagnosis of anemia due to beta thalassemia (including beta+ thalassemia, beta0 thalassemia, hemoglobin E/beta thalassemia), age ≥18, and transfusion history in the previous 24 weeks showing at least six units PRBC and no transfusion-free period greater than 35 days.
- For MDS: documentation of symptomatic anemia due to MDS; IPSS-R risk classification showing Very Low, Low, or Intermediate risk; documentation that del(5q) mutation is not present.
- For MDS ring sideroblast criteria: laboratory/pathology report documenting ring sideroblast percentage and/or documentation of SF3B1 mutation status, and serum erythropoietin (EPO) level when applicable (showing ≤ 500 mU/mL if RS <15% or <5% with SF3B1 mutation).
Key Coverage Criteria
- Anemia in adult patients with beta thalassemia who meet all of the following criteria: Diagnosis of anemia due to beta thalassemia including beta+ thalassemia, beta0 thalassemia, and hemoglobin E/beta thalassemia; Patient is 18 years of age or older; Patient is transfusion dependent as evidenced by both of the following in the previous 24 weeks: Has required regular transfusion of at least six units of packed red blood cells (PRBC); and No transfusion free period greater than 35 days; Prescribed [...]
- Treatment of symptomatic anemia in patients with myelodysplastic syndromes (MDS) who meet all of the following criteria: Diagnosis of symptomatic anemia due to myelodysplastic syndrome (MDS); Patient has lower risk disease as defined as International Prognostic Scoring System (IPSS-R): Very Low, Low, Intermediate; Patient does not have a confirmed mutation with deletion 5q [del(5q)]; One of the following: (a) Both of the following: Ring sideroblasts < 15% (or ring sideroblasts <5% with an SF3B1 [...]
- Anemia in patients with myelodysplastic syndrome/myeloproliferative overlap neoplasm (MDS/MPN) who meet all of the following criteria: Diagnosis of anemia due to myelodysplastic syndrome/myeloproliferative overlap neoplasm (MDS/MPN); Presence of a SF3B1 mutation; Thrombocytosis defined as platelet count ≥ 450 × 10^9 / L; Prescribed by, or in consultation with, a hematologist, oncologist, or other specialist with expertise in the diagnosis and management of MDS/MPN; Dosing is in accordance with t [...]
- Myelofibrosis-associated anemia in patients who meet all of the following criteria: Diagnosis of myelofibrosis-associated anemia; One of the following: (a) Both of the following: Symptomatic splenomegaly and/or constitutional symptoms AND Used in combination with a JAK inhibitor (e.g., Inrebic (fedratinib), Jakafi (ruxolitinib), Ojjaara (momelotinib), Vonjo (pacritinib)); OR (b) No splenomegaly or constitutional symptoms. [...]
- UnitedHealthcare recognizes indications and uses of injectable oncology medications, including therapeutic radiopharmaceuticals, listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence and Consensus of 1, 2A, and 2B as proven and medically necessary (i.e., Reblozyl uses appearing in NCCN with these categories are recognized as covered).
3 Active Policies
UHC-POL-reblozyl — Reblozyl (Luspatercept-Aamt)
UMR-POL-UMR-reblozyl — Reblozyl (Luspatercept-Aamt)
SUREST-POL-SUREST-reblozyl — Reblozyl (Luspatercept-Aamt)
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