| Anthem Blue Cross (HMO, PPO, EPO) |
| Procrit (epoetin alfa) |
| Drugs for the Blood : Drugs for the Blood |
- Anemia:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
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: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
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: 4 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
- PA Applies
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Quantity Limit: limit maximum 12 mL PER 28 day(s)
- Step Therapy: Anemia due to Chemotherapy:
ST Single Brand
- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
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