Reblozyl (luspatercept-aamt) Medication Precertification Request — Coverage Criteria
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Precertification request and required clinical documentation for initiation or continuation of Reblozyl (luspatercept-aamt) for Aetna members; intended for prescribing providers, dispensing providers, and Aetna review staff.
No material clinical or coverage changes in this revision.
Coverage Criteria for Reblozyl (luspatercept-aamt)
Initiation Therapy
Covered when ALL of the following are documented (per form fields):
checkboxes on form request confirmation of testing
form asks Yes/No
form captures both metrics
Continuation Therapy
Continuation covered when ALL of the following are met:
required for continuation requests
required for continuation requests
The precertification form does not include an explicit list of exclusions. Instead, coverage is conditioned on completion of required diagnostic and clinical fields on the two‑page Reblozyl request form. For initiation requests the form requires diagnostic confirmation of beta thalassemia or hemoglobin E/beta‑thalassemia by hemoglobin electrophoresis, high‑performance liquid chromatography (HPLC), or molecular genetic testing, documentation of symptomatic anemia prior to treatment, recording of pretreatment or pretransfusion hemoglobin, and documentation of transfusion history including whether the patient required at least 6 red blood cell units in the previous 24 weeks.
Although the form does not print a formal noncoverage statement, it implies requests may be denied or deemed not medically necessary when required items are missing or thresholds are not met. Examples include absence of diagnostic confirmation by electrophoresis/HPLC/molecular testing, failure to indicate the patient has symptomatic anemia prior to treatment, lack of a recorded pretreatment/pretransfusion hemoglobin, or failure to document the queried transfusion burden such as fewer than 6 RBC units in the prior 24 weeks for the beta thalassemia transfusion‑burden criterion.
Coding: Administration and Diagnosis Codes
| Administration code(s) (CPT) | Administration CPT codes to be provided on the form |
| Primary ICD Code | Primary diagnosis ICD code to be provided |
| Secondary ICD Code | Secondary diagnosis ICD code to be provided |
| Other ICD Code | Other applicable ICD codes |
Provider Actions and Requirements
Precertification required
Precertification (prior authorization) is required for Reblozyl. Submit the completed two-page Reblozyl precertification request form; use the Aetna Precertification Notification phone or fax shown on the form for submission and questions.
- Aetna Precertification Notification Phone: 1-866-752-7021 (TTY: 711)
- Fax: 1-888-267-3277
- For Medicare Advantage Part B: use the Medicare Request Form
Record prior transfusion burden and response
Document the patient's transfusion history and response on the form: indicate whether the patient required at least 6 RBC units in the previous 24 weeks and whether the patient has been receiving regular RBC transfusions defined as ≥2 units per 8 weeks.
- Did the patient require at least 6 red blood cell units in the previous 24 weeks? (Yes/No)
- Has the patient been receiving regular red blood cell transfusions (≥2 units per 8 weeks)? (Yes/No)
- For continuation requests, indicate whether the patient has achieved or maintained a reduction in RBC transfusion burden (Yes/No)
Complete all form fields and attach clinical documentation
Complete all required fields on both pages of the precertification form, including patient demographics, insurance, prescriber and dispensing provider information, product dose and frequency, ICD diagnosis codes, and all required clinical information for initiation or continuation requests.
- Patient demographics and contact information
- Aetna Member ID, group number, and other coverage details
- Prescriber name, licensure (NPI, state license), phone/fax, specialty
- Dispensing provider/place of administration and administration CPT codes
- Requested product, dose, and frequency
- Primary and any secondary ICD-10 codes
- Clinical documentation: diagnosis confirmation, symptomatic anemia, pretreatment/pretransfusion Hgb, transfusion history, and response for continuation
Fraudulent or misleading information may lead to denial and penalties
Do not submit materially false information or conceal material facts; knowingly filing such a request may be treated as fraudulent and can result in denial and criminal or civil penalties.
- Signature is required on the form acknowledgement certifying accuracy.
- The plan may request additional information or clarification to evaluate requests.
Background
Reblozyl (luspatercept‑aamt) is indicated on the form for treatment of certain anemias, including beta thalassemia (including hemoglobin E/beta‑thalassemia) and anemia associated with myelodysplastic syndromes such as myelodysplastic syndrome with ring sideroblasts or related MDS/MPN entities (for example, MDS/MPN‑RS‑T). The form requests confirmation of diagnosis by laboratory or genetic testing and captures baseline hemoglobin and transfusion history to determine eligibility.
Definitions
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