Erythropoietin Stimulating Agents – Procrit Prior Authorization Criteria - Medicare Part D

Note: Procrit also subject to Medicare B vs. D review

Procrit will be approved when ALL of the following are met:

1. The requested medication is being prescribed for ONE of the following: 
   1. 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 
   2. Anemia due to myelosuppressive chemotherapy for a non-myeloid malignancy AND ALL of the following:
      1. 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
      2. 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
      3. The intent of chemotherapy is non-curative OR
   3. Anemia associated with chronic kidney disease in a patient NOT on dialysis AND ALL of the following:
      1. 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
      2. The rate of hemoglobin decline indicates the likelihood of requiring a RBC transfusion AND
      3. The intent of therapy is to reduce the risk of alloimmunization and/or other RBC transfusion related risks OR 
   4. 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 
   5. 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
   6. 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 
2. The patient’s transferrin saturation and serum ferritin have been evaluated AND 
3. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: