CurrentBlue Cross Blue Shield - MassachusettsPolicy 083

Medications For Sickle Cell And Beta Thalassemia Prn

Prior authorization policy for commercial BCBSMA coverage of Reblozyl (luspatercept), Adakveo (crizanlizumab), and Oxbryta (voxelotor) for specified indications in sickle cell disease, beta thalassemia, and selected MDS populations, including initial and continuation criteria and approval lengths.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

Policy083 Medications For Sickle Cell And Beta Thalassemia Prn

Policy CodePolicy 083

Change TypeAnnual review; prior clinical changes documented

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests and supporting documentation to BCBSMA Pharmacy Operations using the Massachusetts standard medication prior authorization form by phone, fax, or mail.

SourceLink

POLICY UPDATE CHANGES

5/2026 Annual Review: Formatting and references updated. No clinical criteria changes.

1/2024 Updated new indications for Reblozyl.

2/2022 Updated age range of Oxbryta.

2/2020 Implemented new policy for Reblozyl, Adakveo, & Oxbryta.

3Medications addressed

3Covered Indications (drug-specific)

6Key numeric thresholds

Coverage Summary

Scope: This BCBSMA prior authorization policy covers three medications — Reblozyl (luspatercept), Adakveo (crizanlizumab), and Oxbryta (voxelotor) — used for specified indications in sickle cell disease, beta thalassemia, and selected myelodysplastic syndrome (MDS) populations. Coverage stance is covered with criteria, with specified initial and continuation clinical criteria and defined approval lengths. Key covered indications include: (1) Adakveo for vasoocclusive crises (VOCs) in sickle cell disease (patients ≥ 16 years, hemoglobin > 4.0 g/dL, 2–10 VOCs in prior 12 months); (2) Reblozyl for regularly transfused beta thalassemia (patients ≥ 18 years, defined as 6–20 RBC units in the most recent 24 weeks, no transfusion-free period ≥ 35 days, platelet count < 1000 x 10^9/L) and for selected MDS indications (ESA‑naïve very low- to intermediate-risk MDS and MDS-RS/MDS/MPN-RS-T with specified transfusion requirements); and (3) Oxbryta for sickle cell disease in patients ≥ 4 years with hemoglobin between 5.5 and 10.5 g/dL.

Exclusions & Definitions

Exclusions and limits implied by the criteria: patients receiving regularly scheduled blood (RBC) transfusion therapy (also termed chronic/prophylactic/preventive transfusion) are excluded from Adakveo eligibility. For Reblozyl when used for beta thalassemia, the policy excludes patients with a diagnosis of Hemoglobin S/β-thalassemia or alpha (α)-thalassemia. The policy also limits use to the listed indications and states it does not cover these medications for other, unlisted conditions.

Label	Definition
Regularly transfused
Defined for Reblozyl beta thalassemia as 6-20 RBC units in the most recent 24 weeks
Regularly scheduled blood (RBC) transfusion therapy
Also termed chronic, prophylactic, or preventive transfusion (patients on this are excluded for Adakveo)

Provider Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Reblozyl, Adakveo, and Oxbryta for BCBSMA Commercial plans. Requests must be submitted to Pharmacy Operations by phone, fax, or mail. Use the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or print and fax Form #434 as applicable.

Pharmacy Operations phone: 1-800-366-7778
Pharmacy Operations fax: 1-800-583-6289
Mailing address: Blue Cross Blue Shield of Massachusetts, Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043
Massachusetts Standard Medication Prior Authorization form (eForm) or Form #434

Documentation Required

Supporting Documentation Required

Providers must submit supporting clinical documentation to demonstrate the member meets all policy clinical criteria. Acceptable documentation includes chart notes, laboratory results, transfusion records, documentation of vaso-occlusive crisis (VOC) frequency, hemoglobin levels, and evidence of response to therapy when requesting continuation.

Chart notes and clinical summaries
Relevant lab results (e.g., hemoglobin)
Transfusion records (dates and units)
VOC frequency documentation (number in prior 12 months)
Documentation of response for continuation requests (VOC reduction or Hb change)

Billing Rule

Benefit Determination

Codes listed in the policy (CPT/HCPCS/ICD) are provided for informational purposes only. Inclusion or exclusion of a code does not guarantee member coverage or provider reimbursement; coverage determination depends on the individual member's contract benefits.

Verify coverage and reimbursement by reviewing the member's contract benefits at time of service

Prior Authorization

Approval Lengths

Approval durations vary by product and indication. Initial approvals and continuation approvals are granted as follows:

Adakveo (crizanlizumab): Initial up to 6 months; continuation up to 12 months
Reblozyl (luspatercept): Initial for MDS‑RS 12 weeks (other Reblozyl initial approvals governed by clinical criteria); continuation up to 12 months
Oxbryta (voxelotor): Initial up to 6 months; continuation up to 12 months

Documentation Required

Individual Consideration (Exception Requests)

Providers may request individual consideration (exception requests) for patients who do not meet the policy criteria by submitting additional clinical documentation and supporting references to Pharmacy Operations at BCBSMA. Include clinical notes, treatment history, literature or compendia references, and any other information that supports medical necessity.

Include clinical notes, treatment failure history, and supporting literature when requesting an exception
Submit requests to: Blue Cross Blue Shield of Massachusetts, Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043
Providers may call, fax, or mail relevant clinical information for individual consideration

Clinical Evidence & References

Evidence references: package inserts cited in the policy include Reblozyl [package insert], Celgene Corporation: 5/2024; Adakveo [package insert], Novartis Pharmaceuticals Corporation: 6/2024; and Oxbryta [package insert], Global Blood Therapeutics, Inc.: 8/2023. The policy notes that full clinical trial data are available in the respective package inserts and does not duplicate clinical trial metrics in this section.

Background

Background: This BCBSMA policy defines prior authorization requirements and clinical criteria for Reblozyl, Adakveo, and Oxbryta and applies to BCBSMA commercial formulary products (Managed Care, PPO/EPO, Indemnity, MEDEX with Rx, Managed Blue for Seniors). It references the Quality Care Dosing guidance and the Medical Benefit Prior Authorization list as background context for coverage and formulary status.

Revision History

2/2020policy_added

Implemented new policy for Reblozyl, Adakveo, & Oxbryta.

2/2022policy_revised

Updated age range of Oxbryta.

1/2024policy_revised

Updated new indications for Reblozyl.

5/2026annual_reviewLatest

Annual Review: Formatting and references updated. No clinical criteria changes.