Provider Alert! Prior authorization update for Reblozyl, procedure code J0896

Attention: Hematologists
Effective Date: September 1, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) will align the prior authorization requirements for Reblozyl with Texas Medicaid Healthcare Partnership (TMHP) guidance. A prior authorization will be required beginning September 1, 2020.
Resources:
TMHP Notice July 17, 2020
TMHP Notice July 21, 2020
How this impacts providers: Reblozyl (J0896) is a benefit for people 18 years of age and older, and is approved for treatment of the following:

• Anemia in adults with beta thalassemia requiring red blood cell (RBC) transfusions
• Anemia failing an erythropoiesis stimulating agent and requiring two or more red blood cell units over eight weeks in adults with low to intermediate-risk myelodysplastic syndrome with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T)

Reblozyl (J0896) must be ordered by, or in consultation with, a hematologist.

Next steps for providers: Prior Authorization Requirements
Prior authorization requests for procedure code J0896 must be submitted with a Special Medical Prior Authorization (SMPA) Request Form. The completed Special Medical Prior Authorization (SMPA) Request Form must be maintained by the prescribing provider in the client’s medical record and is subject to retrospective review.

A person must be 18 years of age or older and meet the following criteria for initial approval:

• For anemia with beta thalassemia requiring regular RBC transfusions:
• Person must have a diagnosis of beta thalassemia
• Person required regular RBC transfusions of six or more units within the previous 24 weeks and has had no transfusion-free period for 35 days or longer during the review period
• For anemia failing an erythropoiesis stimulating agent:
• Person must have a diagnosis of myelodysplastic syndrome classified as low to intermediate risk disease
• Person must require RBC transfusions of two or more units over a period of eight weeks
• Person must be ineligible or must have failed prior erythropoietin stimulating agent treatment

For prior authorization renewal, a person must meet the initial age and diagnosis criteria and meet the following requirements:

• For anemia with beta thalassemia requiring regular RBC transfusions:
• Person had a positive response/hematological improvement demonstrated by a reduction in RBC transfusion as indicated by the prescribing physician
• Person previously received treatment with Reblozyl without complications
• For anemia failing an erythropoiesis stimulating agent:
• Person had a positive response demonstrated by RBC transfusion independence during any consecutive eight-week period or a decrease in transfusion requirement as indicated by the prescribing physician
• Person previously received treatment with Reblozyl without complications

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers