darbepoetin alfa — CareFirst (Caremark)
Anemia due to chronic kidney disease (CKD) including patients on dialysis and not on dialysis
Initial criteria
- Member has pretreatment hemoglobin < 10 g/dL
- Member has been assessed for iron deficiency anemia and has adequate iron stores (TSAT ≥ 20% within the prior 3 months) or is receiving iron therapy
- Member is not using other erythropoiesis-stimulating agents concomitantly
Reauthorization criteria
- After at least 12 weeks of treatment, member has a rise in hemoglobin ≥ 1 g/dL
- Current hemoglobin < 12 g/dL
- Member continues to be assessed for iron deficiency and has adequate iron stores (TSAT ≥ 20% within the prior 3 months) or is receiving iron therapy
- Member is not using other erythropoiesis-stimulating agents concomitantly
Approval duration
12 weeks