Epoetin Alfa

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for anemia secondary to HIV infection or HIV drug therapy, myelodysplasia, and chronic hepatitis C treatment from ribavirin and interferon therapy.
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. Treatment of anemia due to HIV infection or HIV drug therapy is provided when 1. Hgb/Hct is less than 33% or 11 g/dL OR 2. erythropoietin is less than or equal to 500 units/L AND patient is symptomatic or has required transfusions. Anemia due to chronic hepatitis C treatment from ribavirin and interferon therapy is provided when Hgb/Hct is less than or equal to 33% or 11 g/dL. For use in reducing the need for allogenic blood transfusions in surgery patients is provided when 1. the surgery is elective, non-vascular or non-cardiac AND 2. Hgb is less than or equal to 13 g/dL AND 3. patient refuses or cannot undergo autologous donation prior to surgery.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	1 month- allogeneic blood transfusions, 3 months - chemotherapy, 12 months - other indications
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. Renewals for anemia due to HIV infection or HIV drug therapy is provided when Hgb/Hct is less than or equal to 36% or 12 g/dL. Patients renewing anemia due to cancer-chemotherapy or chronic hepatitis C treatment from ribavirin and interferon therapy must meet required medical information.

Last Modified on 12/19/2012