ACCRUFER (ferric maltol)

ACCRUFER (ferric maltol)

Self-Administration – oral

Indications for Prior Authorization:

• Indicated for the treatment of iron deficiency in adults

Coverage Criteria:

For diagnosis of iron deficiency:

• Dose does not exceed 30 mg twice daily, AND
• Patient is 18 years of age or older, AND
• Patient has a diagnosis of iron deficiency, AND
• Tried and failed two different forms of oral iron products (e.g., ferrous fumarate, ferrous gluconate, ferrous sulfate, polysaccharide-iron complex)

Reauthorization Criteria:

For diagnosis of iron deficiency:

• Dose does not exceed 30 mg twice daily, AND
• Member is responding positively to therapy (e.g., ferritin levels are within normal range)

Coverage Duration:

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:

• Avoid use of Accrufer® in patients with an active inflammatory bowel disease (IBD) flare, as there is potential risk of increased inflammation in the gastrointestinal tract.
• Contraindicated in patients with a history of hemochromatosis and other iron overload syndromes. Use may result in iron overdose.
• Contraindicated in patients with a history of receiving repeated blood transfusions. Use may result in iron overload.
• Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6. Keep this product out of reach of children. In case of accidental overdose, call a doctor or poison control center immediately.

Policy Updates:

• 10/19/2021 – New policy approved by P&T.

References:

• Accrufer Prescribing Information. Shield TX (UK) Ltd. August 2021.