Epogen — Blue Cross Blue Shield of Montana

Initial criteria

• Iron stores evaluated before starting ESA: blood ferritin ≥ 100 ng/mL OR transferrin saturation ≥ 20%
• Iron stores maintained before and while using ESA therapy
• Blood pressure adequately controlled and closely monitored before and during therapy
• ESA dose is the lowest dose sufficient to avoid need for red blood cell transfusion
• Prescriber is a specialist in the diagnosis area (e.g., nephrologist, oncologist) OR has consulted with one
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia allowed: AHFS or DrugDex 1, 2a, or 2b, NCCN 1, 2a, 2b

Approval duration

12 months (BCBSIL and BCBSMT); 3 months for BCBSNM allogenic transfusion surgery; 1 month for all other plans for surgery; 6 months for anemia due to chemotherapy or other diagnoses; 12 months for chronic kidney disease, myelodysplastic syndrome, or zidovudine-related anemia; 12 months for NM Fully Insured/HIM or OH Fully Insured/HIM members with other FDA or compendia supported indications)