Procrit — Blue Cross Blue Shield of New Mexico

Initial criteria

• Prior to starting the requested agent, the patient's iron stores were evaluated, and blood ferritin found to be at least 100 ng/mL OR transferrin saturation found to be at least 20%
• Iron stores will be maintained before starting and while using ESA therapy
• Blood pressure will be adequately controlled and closely monitored before and during ESA therapy
• The ESA dose is the lowest dose that will gradually increase hemoglobin concentration to the lowest level sufficient to avoid the need for red blood cell transfusion
• For Epoetin alfa (Epogen, Procrit) or Epoetin alfa-epbx (Retacrit): ONE of the following applies:
• • Anemia associated with chronic kidney disease (including ESRD) and the patient has Hgb <11 g/dL (or <10 g/dL for initiation) and agent used to reduce transfusion need
• • Anemia in cancer patients with metastatic non-myeloid malignancies AND patient has myelosuppressive chemotherapy, anemia caused by it, not due to other causes, therapy not curative, and Hgb ≤12 g/dL or approaching/fallen below 10 g/dL for initiation
• • Anemia related to AZT therapy in HIV-infected patients and endogenous erythropoietin ≤500 mUnits/mL
• • To reduce need for allogeneic transfusion in elective, non-cardiac, non-vascular surgery patients AND Hgb <13 g/dL, not candidate for autologous transfusion, high risk for blood loss
• • Anemia in patients with myelodysplastic syndromes to reduce transfusion dependency
• • Anemia associated with Hepatitis C treated with ribavirin plus interferon or peginterferon, other causes ruled out, failed response after ribavirin dose reduction, Hgb <10 g/dL or symptomatic with Hgb <11 g/dL
• For Darbepoetin alfa (Aranesp): ONE of the following applies:
• • Anemia associated with chronic kidney disease (including ESRD) and Hgb <11 g/dL (or <10 g/dL for initiation) and used to reduce transfusion need
• • Anemia in cancer patients with non-myeloid metastatic malignancies undergoing myelosuppressive chemotherapy, caused by chemotherapy, not curative intent, and Hgb ≤12 g/dL or approaching/fallen below 10 g/dL for initiation
• • Anemia in patients with myelodysplastic syndromes to reduce transfusion dependency
• For Methoxy polyethylene glycol-epoetin beta (Mircera): Anemia associated with chronic kidney disease (including ESRD) and Hgb <11 g/dL (or <10 g/dL for initiation) and used to reduce transfusion need
• Patient has another FDA labeled or compendia-supported indication with hemoglobin within respective labeled or compendia range (initiation or maintenance)
• Prescriber is a specialist in the area of diagnosis (e.g., nephrologist, oncologist) or has consulted with one
• Patient has no FDA labeled contraindications

Approval duration

varies