- Prior Authorization: Anemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
- Anemia:
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Dialysis status: not on dialysis
Initial Therapy HgbHCT Requirements: Hgb < 12 g/dL (females) OR Hgb < 13 g/dL (males)
Initial Therapy Iron Stores Requirements: 2 of Serum ferritin < 15 ng/mL;Serum ferritin < 30 ng/mL if pregnant;Serum ferritin <= 41 ng/mL ;Serum ferritin <= 500 ng/mL or TSAT <= 30%;TSAT < 12%;TSAT < 20%
Discontinuation requirements: No
Documentation Requirements: Chart notes
Reauthorization Requirements HgbHCT: Hgb < 12 g/dL (females) OR Hgb < 13 g/dL (males)
Reauthorization Requirements Iron Stores: Serum ferritin <=500 ng/mL OR TSAT <=30%
- Step Therapy: Anemia:
ST Single Generic
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