Vafseo — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has been receiving dialysis for at least 3 consecutive months; AND
• Patient meets ONE of the following (a or b):
• a) Patient meets BOTH of the following (1 and 2):
• (1) Patient is currently receiving an erythropoiesis-stimulating agent and transitioning to Vafseo; AND
• (2) Patient has a hemoglobin level ≤ 12.0 g/dL; OR
• b) Patient meets BOTH of the following (1 and 2):
• (1) Patient is NOT currently receiving an erythropoiesis-stimulating agent; AND
• (2) Patient has a baseline (prior to initiation of Vafseo) hemoglobin level < 11 g/dL; AND
• 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; AND
• The medication is prescribed by or in consultation with a nephrologist

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Patient has been receiving dialysis for at least 3 consecutive months; AND
• Patient has a hemoglobin level ≤ 12.0 g/dL; AND
• 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; AND
• The medication is prescribed by or in consultation with a nephrologist; AND
• According to the prescriber, patient has experienced a response to therapy

Approval duration

initial 6 months; reauth 1 year