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.

 

Last review date: October 19, 2021

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