Medicare Drug Policy
Version Date: 01/01/2025
Note: Procrit also subject to Medicare B vs. D review
Procrit will be approved when ALL of the following are met:
- The requested medication is being prescribed for ONE of the following:
- To reduce the possibility of allogeneic blood transfusion in a surgery patient AND the patient’s hemoglobin level is greater than 10 g/dL but less than or equal to 13 g/dL OR
- Anemia due to myelosuppressive chemotherapy for a non-myeloid malignancy AND ALL of the following:
- The patient’s hemoglobin level is less than 10 g/dL for patients initiating Erythropoietin Stimulating Agent (ESA) therapy OR less than 12 g/dL for patients stabilized on therapy (measured within the previous 4 weeks) AND
- The patient is being concurrently treated with chemotherapy with or without radiation (there must be a minimum of 2 additional months of planned chemotherapy) AND
- The intent of chemotherapy is non-curative OR
- Anemia associated with chronic kidney disease in a patient NOT on dialysis AND ALL of the following:
- The patient’s hemoglobin level is less than 10 g/dL for patients initiating ESA therapy OR 11 g/dL or less for patients stabilized on therapy (measured within the previous 4 weeks) AND
- The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion AND
- The intent of therapy is to reduce the risk of alloimmunization and/or other RBC transfusion related risks OR
- Anemia due to myelodysplastic syndrome AND the patient’s hemoglobin level is less than 12 g/dL for patients initiating ESA therapy OR less than or equal to 12 g/dL for patients stabilized on therapy (measured within the previous 4 weeks) OR
- Anemia resulting from zidovudine treatment of HIV infection AND the patient’s hemoglobin level is less than 12 g/dL for patients initiating ESA therapy OR less than or equal to 12 g/dL for patients stabilized on therapy (measured within the previous 4 weeks) OR
- Another indication that is supported in CMS approved compendia for the requested medication AND the patient’s hemoglobin level is less than 12 g/dL for patients initiating ESA therapy OR less than or equal to 12 g/dL for patients stabilized on therapy (measured within the previous 4 weeks) AND
- The patient’s transferrin saturation and serum ferritin have been evaluated AND
- The patient does NOT have any FDA labeled contraindications to the requested medication
Length of Approval:
| Indication | Length of Approval |
|---|---|
| Allogenic blood transfusion in surgery patients | 1 month |
| Myelosuppressive chemotherapy, non-myeloid malignancy | 6 months |
| Chronic kidney disease NOT ON DIALYSIS | 12 months |
| Myelodysplastic syndrome | 12 months |
| Zidovudine treatment for HIV | 12 months |
| All other diagnoses | 12 months |
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