daprodustat — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following:
• 1. The requested agent is eligible for continuation of therapy AND ONE of the following:
• • Information has been provided that indicates the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
• • The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
• OR
• 2. The patient has a diagnosis of chronic kidney disease AND ALL of the following:
• • The patient has been on dialysis for at least 4 months AND
• • The patient's hemoglobin was measured in the previous 4 weeks AND
• • ONE of the following:
• – The patient is currently using an erythropoietin receptor agonist (e.g., Aranesp, Epogen, Mircera, Procrit, Retacrit) AND the patient's hemoglobin does NOT exceed 12 g/dL (medical records required)
• – The patient is NOT currently using an ESA AND the patient's hemoglobin is ≤ 11 g/dL
• • The patient's ferritin was measured in the previous 4 weeks AND ferritin > 100 mcg/L AND
• • ONE of the following:
• – The patient's transferrin saturation (TSAT) is > 20%
• – The patient's TSAT is ≤ 20% and is due to recent infection
• • Other causes of anemia (e.g., pernicious anemia, thalassemia major, sickle cell) have been addressed
• OR
• 3. The patient has another FDA approved indication for the requested agent and route of administration AND:
• • The patient's age is within FDA labeling for the indication OR prescriber has provided support for use for patient's age
• AND
• • The prescriber is a specialist in the area of the patient's diagnosis (e.g., nephrologist) or has consulted with one
• • The patient will NOT be using the requested agent in combination with an ESA (e.g., Aranesp, Epogen, Mircera, Procrit, Retacrit)
• • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• • The patient has been previously approved for the requested agent through the plan's Prior Authorization process AND
• • The patient has had clinical benefit with the requested agent (e.g., increase in hemoglobin) AND
• • The patient's hemoglobin was measured within the previous 4 weeks AND
• • The patient's hemoglobin does NOT exceed 12 g/dL (medical records required) AND
• • The prescriber is a specialist in the area of the patient's diagnosis (e.g., nephrologist) or has consulted with a specialist AND
• • The patient will NOT be using the requested agent in combination with an ESA (e.g., Aranesp, Epogen, Mircera, Procrit, Retacrit) AND
• • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 6 months; renewal 12 months