Jesduvroq (daprodustat) — Highmark
anemia due to chronic kidney disease (CKD) in adults who are dialysis-dependent
Initial criteria
- age ≥ 18 years
- diagnosis of anemia in chronic kidney disease (ICD-10: D63.1)
- diagnosis of dialysis-dependent chronic kidney disease (ICD-10: Z99.2)
- IF Jesduvroq requested: member has been receiving dialysis for at least 4 months
- IF Vafseo requested: member has been receiving dialysis for at least 3 months
- clinical documentation that hemoglobin level is < 11 g/dL
- prescribed by or in consultation with a nephrologist or hematologist
- member has experienced therapeutic failure, contraindication, or intolerance to one intravenous iron product OR intravenous iron products are not appropriate
- member has experienced therapeutic failure, contraindication, or intolerance to one erythropoiesis-stimulating agent
Reauthorization criteria
- prescriber attests that the member has experienced a clinically meaningful increase in hemoglobin level from baseline
- clinical documentation that hemoglobin level is ≤ 11 g/dL
Approval duration
initial: up to 6 months; reauthorization: up to 12 months