Retacrit — CareFirst (Caremark)
Anemia due to zidovudine in HIV-infected patients
Initial criteria
- Currently receiving zidovudine at ≤ 4200 mg/week
- Pretreatment hemoglobin less than 10 g/dL
- Pretreatment serum erythropoietin level ≤ 500 mU/mL
- Member assessed for iron deficiency anemia and has adequate iron stores (TSAT ≥ 20% within the prior 3 months) or receiving iron therapy
Reauthorization criteria
- Current hemoglobin less than 12 g/dL
- Member continues zidovudine therapy
Approval duration
12 months