Epogen — Point32Health

Initial criteria

• Documentation of one (1) of the following:
• a. All of the following: i. Prescribed for the treatment of anemia due to chronic kidney disease; rheumatoid arthritis; hepatitis C treatment with ribavirin plus interferon alfa or peginterferon alfa; zidovudine in HIV infection with pre-treatment serum erythropoietin < 500 mU/mL; patient whose religious beliefs forbid blood transfusions; or due to cancer in a patient receiving palliative therapy AND ii. Patient has pre-treatment hemoglobin < 10 g/dL AND iii. Adequate iron stores (serum transferrin saturation ≥ 20% within prior 3 months or currently receiving iron therapy)
• OR b. All of the following: i. Prescribed for the treatment of anemia due to primary myelofibrosis, post-polycythemia vera myelofibrosis, post-essential thrombocytopenia myelofibrosis, or myelodysplastic syndrome AND ii. Pre-treatment serum erythropoietin < 500 mU/mL AND iii. Pre-treatment hemoglobin < 10 g/dL AND iv. Adequate iron stores (serum transferrin saturation ≥ 20%)
• OR c. Both of the following: i. Prescribed for anemia due to congestive heart failure with pre-treatment hemoglobin < 9 g/dL AND ii. Adequate iron stores (serum transferrin saturation ≥ 20%)
• OR d. Both of the following: i. Prescribed for reduction of allogeneic red blood cell transfusion in elective, non-cardiac, nonvascular surgery with pre-treatment hemoglobin < 13 g/dL AND ii. Adequate iron stores (serum transferrin saturation ≥ 20%)
• OR e. Both of the following: i. Prescribed for anemia due to a malignancy AND ii. Adequate iron stores (serum transferrin saturation ≥ 20%)