CurrentMass General Brigham Health PlanPolicy N/A

Triferic (ferric pyrophosphate citrate) - iron replacement for HDD-CKD

This policy governs prior authorization and coverage criteria for Triferic (ferric pyrophosphate citrate) for adult members with hemodialysis-dependent chronic kidney disease (HDD-CKD) under Mass General Brigham Health Plan pharmacy and medical benefits.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTriferic (ferric pyrophosphate citrate) - iron replacement for HDD-CKD

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of two trials of appropriate alternatives, a diagnosis of HDD-CKD, and clinical rationale when using a product from a non-rebate-program manufacturer; for continuation submit medical records showing therapeutic response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1maximum approval duration

2required trials of appropriate alternatives

adult HDD-CKDindicated population

Authorization Criteria for Triferic (ferric pyrophosphate citrate)

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ALL of the following

Two trials of all appropriate alternatives whose manufacturers participate in the federal rebate program
Trials must be of appropriate alternatives; the document states "2_ Trials" indicating requirement for two trials.
Diagnosis: replacement of iron to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease (HDD-CKD)
Documentation of clinical rationale for use of a drug whose manufacturer does not participate in the federal rebate program
Applies when provider requests a non-rebate-program manufacturer's product.

Supplementary limitations: Triferic has not been studied in patients receiving home hemodialysis and therefore use in that setting is not supported by available evidence. In addition, Triferic is not intended for use in patients receiving peritoneal dialysis. These limitations apply in the context of the policy scope, which governs prior authorization and coverage criteria for Triferic (ferric pyrophosphate citrate) for adult members with hemodialysis-dependent chronic kidney disease (HDD-CKD) under the Mass General Brigham Health Plan pharmacy and medical benefits.

Relevant Diagnoses and Product Coding

Relevant ICD-10 diagnoses (as described in coverage criteria)ICD-10

Document references hemodialysis-dependent chronic kidney disease (HDD-CKD) as the indication; specific ICD-10 codes not listed in the policy.

Drug / ProductNDC|HCPCSCovered

Triferic (ferric pyrophosphate citrate)

Iron replacement product indicated to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease.

Authorization, Documentation, and Approval Limits

Prior Authorization

Prior authorization required

Prior authorization is required; authorization may be reviewed case-by-case for members new to the plan who are currently receiving treatment with the requested medication. For initial approvals, submit documentation of two trials of appropriate alternatives (manufacturers in federal rebate program), diagnosis of HDD-CKD, and clinical rationale for use if product manufacturer is not in the rebate program.

Documentation of two trials of all appropriate alternatives whose manufacturers participate in the federal rebate program
Diagnosis: replacement of iron to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease (HDD-CKD)
Clinical rationale if the requested product's manufacturer does not participate in the federal rebate program

Documentation Required

Documentation for continuation

For continuation of therapy, the physician must submit medical records (e.g., chart notes) documenting a therapeutic response to treatment.

Note

Approval duration limit

Approvals will be granted for up to 1 year.

Maximum approval duration: 1 year

Clinical Background

Triferic (ferric pyrophosphate citrate) is an iron replacement product indicated to replace iron and maintain hemoglobin in adult patients receiving hemodialysis for chronic kidney disease (hemodialysis-dependent CKD). It is intended for use in adult in-center hemodialysis patients; the product has not been studied in home hemodialysis and is not intended for use in peritoneal dialysis patients.

References and Prior Authorization Contact Information

Triferic [package insert]: Rockwell Medical, Inc; 2018 Apr.

Contact Information

Non‑Specialty Medications — Phone800-711-4555

Non‑Specialty Medications — Fax844-403-1029

Non‑Specialty Medications — PlansAll Plans

Specialty Medications — Phone877-519-1908

Specialty Medications — Fax855-540-3693

Specialty Medications — PlansAll Plans