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