Retacrit — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Prior to starting the requested agent, the patient's iron stores were evaluated, and blood ferritin ≥ 100 ng/mL OR transferrin saturation ≥ 20%
• Iron stores will be maintained before 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 RBC transfusion
• For chronic kidney disease: Hgb < 11 g/dL (or < 10 g/dL for patients initiating ESA therapy) and used to reduce need for transfusions
• For cancer patients: undergoing myelosuppressive chemotherapy, anemia caused by chemotherapy, anemia not due to other causes, therapy outcome not cure, Hgb ≤ 12 g/dL (or approaching/<10 g/dL when initiating)
• For AZT therapy: endogenous serum erythropoietin ≤ 500 mUnits/mL
• For pre-operative use: elective, non-cardiac, non-vascular surgery, Hgb < 13 g/dL, not candidate for autologous transfusion, high risk of perioperative blood loss
• For myelodysplastic syndromes: used to reduce transfusion dependency
• For Hepatitis C: combination ribavirin + interferon, other causes ruled out, severe anemia despite ribavirin dose reduction by 200 mg/day (except if cirrhosis, post-transplant, or HIV co-infection), Hgb < 10 g/dL or symptomatic and Hgb < 11 g/dL
• The prescriber is a specialist in the area of diagnosis or has consulted with one
• Patient has no FDA labeled contraindications

Approval duration

CKD or MDS or zidovudine-related anemia: 12 months; chemotherapy-related anemia: 6 months; perioperative anemia: 1 month (BCBSNM 3 months); other diagnoses: 6 months