Jesduvroq (daprodustat tablets - GlaxoSmithKline) — Cigna

Initial criteria

• Patient is age ≥ 18 years
• Patient has been receiving dialysis for at least 4 consecutive months
• Patient meets ONE of the following (a or b): a) Patient meets BOTH of the following: (1) Patient is currently receiving an erythropoiesis-stimulating agent and transitioning to Jesduvroq; AND (2) Patient has a hemoglobin level ≤ 12.0 g/dL; OR b) Patient meets BOTH of the following: (1) Patient is NOT currently receiving an erythropoiesis-stimulating agent; AND (2) Patient has a baseline (prior to initiation of Jesduvroq) hemoglobin level < 11 g/dL
• Patient meets ONE of the following (a or b): a) Patient is currently receiving iron therapy; OR b) According to the prescriber, patient has adequate iron stores
• The medication is prescribed by or in consultation with a nephrologist

Reauthorization criteria

• Patient is age ≥ 18 years
• Patient has been receiving dialysis for at least 4 consecutive months
• Patient has a hemoglobin level ≤ 12.0 g/dL
• Patient meets ONE of the following (a or b): a) Patient is currently receiving iron therapy; OR b) According to the prescriber, patient has adequate iron stores
• According to the prescriber, patient has experienced a response to therapy (e.g., an increase or stabilization in hemoglobin levels or a reduction or absence in red blood cell transfusions)
• The medication is prescribed by or in consultation with a nephrologist

Approval duration

initial: 6 months; reauth: 1 year