darbepoetin alfa — CareFirst (Caremark)

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 have MDS
• 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