Mircera — CareFirst (Caremark)

Initial criteria

• Member has diagnosis of anemia associated with chronic kidney disease (CKD)
• Pretreatment hemoglobin less than 10 g/dL for adult members
• For pediatric members age 3 months to 17 years, converting from another erythropoiesis-stimulating agent (ESA) after their hemoglobin level was stabilized (e.g., 10 to 12 g/dL)
• Member is assessed for iron deficiency anemia and has adequate iron stores (serum transferrin saturation level ≥ 20% within prior 3 months) or is receiving iron therapy
• Member will not use Mircera concomitantly with another erythropoiesis-stimulating agent

Reauthorization criteria

• Member has been treated with Mircera for at least 12 weeks and has demonstrated a response with a rise in hemoglobin ≥ 1 g/dL
• Members with less than 12 weeks of treatment who have not yet responded may receive authorization of up to 12 weeks to allow time to demonstrate a response
• Current hemoglobin less than 12 g/dL
• Member is assessed for iron deficiency anemia and has adequate iron stores (serum transferrin saturation level ≥ 20% within prior 3 months) or is receiving iron therapy
• Member will not use Mircera concomitantly with another erythropoiesis-stimulating agent

Approval duration

12 weeks