darbepoetin alfa — CareFirst (Caremark)
Anemia due to myelosuppressive chemotherapy in patients with non-myeloid malignancy
Initial criteria
- Member has pretreatment hemoglobin < 10 g/dL
- Anemia is due to concomitant myelosuppressive chemotherapy with at least 2 additional months of planned chemotherapy upon initiation
- 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 have non-myeloid malignancy receiving myelosuppressive chemotherapy
- Member has adequate iron stores (TSAT ≥ 20% within 3 months) or is receiving iron therapy
- Member is not using other erythropoiesis-stimulating agents concomitantly
Approval duration
12 weeks