Darbepoetin Alfa

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for anemia secondary to myelodysplasia.
Exclusion Criteria:
Required Medical Information:	Treatment of anemia due to CRF for patients on dialysis is provided when either 1. Hgb/Hct is less than 30% or 10g/dL OR 2. patient is symptomatic or has required a transfusion. Treatment of anemia due to CRF/CRI for patients NOT on dialysis is provided when either 1. Hgb/Hct is less than 30% or 10g/dL OR 2. patient is symptomatic or has required a transfusion. Anemia due to cancer-chemotherapy is provided when 1. patient is currently receiving myelosuppressive chemotherapy or it has been 6 weeks or less following the completion of the final dose of myelosuppressive chemotherapy AND 2. Hgb/Hct is less than 30% or 10 g/dL. Myelodysplasia related anemia is provided when 1. Hgb/Hct is less than 30% or 10 g/dL AND 2. erythropoietin level is less than or equal to 500 units/L.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	3 months - anemia due to cancer-chemotherapy, 12 months - CRF/CRI or myelodysplasia related anemia
Other Criteria:	Renewals coverage for anemia due to CRF for patients on dialysis is provided when either 1. Hgb/Hct is less than 33% or 11g/dL OR 2. prescriber indicates the dose will be held or titrated downward. Renewals coverage for anemia due to CRF/CRI for patients NOT on dialysis is provided when either 1. Hgb/Hct is less than 30% or 10g/dL OR 2. prescriber indicates the dose will be held or titrated downward. Renewals for myelodysplasia related anemia is provided when 1. Hgb/Hct is less than or equal to 36% or 12 g/dL AND 2. in the presence of therapeutic benefit, if Hgb/HCT has increased or stabilized, or if the need for transfusions has decreased. Patients renewing for cancer-chemotherapy related anemia must meet required medical information.

Last Modified on 12/19/2012