Accrufer (ferric maltol) — Highmark

Initial criteria

• age ≥ 18 years
• clinical documentation supports diagnosis of iron deficiency (ICD-10: D50.8, D50.9)
• If female, hemoglobin level < 12 g/dL OR if male, hemoglobin level < 13 g/dL
• therapeutic failure, contraindication, or intolerance to both of the following: dietary modification to include iron rich foods AND over-the-counter iron replacement therapy for at least 3 months

Reauthorization criteria

• prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

initial: up to 6 months; reauthorization: up to 12 months