Anthem Blue Cross (HMO, PPO, EPO) |
Aranesp SureClick (Polysorbat) 40 Mcg/0.4 Ml Pnij (darbepoetin alfa in polysorbat) |
Drugs for the Blood : Drugs for the Blood |
- Anemia:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Dialysis status: Patients on dialysis and not on dialysis
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
Discontinuation requirements: Yes
Documentation Requirements: blood pressure is adequately controlled before initiation and during therapy
Titration Requirements: 1 of Maintain Hgb = 10 g/dL for non-dialysis patients;Maintain Hgb range 10 - 11 g/dL for dialysis patients
Anemia due to Chemotherapy: Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
Diagnosis Types: 3 of anticipated outcome of chemotherapy is not cure;concomitant myelosuppresive chemotherapy;minimum of two additional months of planned chemotherapy;non-myeloid malignancy
Dose Increase Requirements: No
Discontinuation requirements: Yes
- Prior Authorization: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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