darbepoetin alfa — Blue Cross Blue Shield of Illinois

Initial criteria

• Prior to starting the requested agent, the patient's iron stores were evaluated and ferritin ≥ 100 ng/mL OR transferrin saturation ≥ 20%
• Iron stores will be maintained before starting and while using ESA therapy
• Blood pressure will be adequately controlled and monitored before and during ESA therapy
• ESA dose is the lowest dose sufficient to avoid the need for RBC transfusion
• Prescriber is a specialist in the patient’s diagnosis area or has consulted one
• Patient does NOT have FDA labeled contraindications to the requested agent
• For epoetin alfa (Epogen, Procrit) or epoetin alfa-epbx (Retacrit): used for at least one of the following—(1) anemia of CKD with Hgb <11 g/dL (or <10 g/dL if initiating), (2) anemia with myelosuppressive chemotherapy in non-myeloid metastatic malignancy meeting listed sub-criteria, (3) anemia due to AZT with serum erythropoietin ≤500 mU/mL, (4) pre-operative use in elective non-cardiac, non-vascular surgery with Hgb <13 g/dL and high blood loss risk, (5) anemia with myelodysplastic syndromes, (6) anemia with Hepatitis C meeting sub-criteria including Hgb <10 g/dL or symptomatic <11 g/dL
• For darbepoetin alfa (Aranesp): used for (1) anemia of CKD with Hgb criteria as above, (2) anemia with myelosuppressive chemotherapy where therapy not curative and Hgb ≤12 g/dL, (3) anemia in myelodysplastic syndromes
• For methoxy polyethylene glycol-epoetin beta (Mircera): used for anemia of CKD with Hgb criteria as above
• Alternatively, other FDA labeled indication or compendia supported indication with Hgb within labeled or compendia range may qualify

Approval duration

BCBSIL/BCBSMT 12 months; others—CKD/MDS/HIV 12 months; anemia due to myelosuppressive chemotherapy 6 months; allogeneic blood transfusion 1–3 months per plan; other diagnoses 6 months; NM/OH rare disease provision 12 months