- For the treatment of anemia due to chronic kidney disease (CKD) in adult patients on dialysis.
|Drug||Dosing Regimen||Dose Limit/ Maximum Dose|
ProcritR (epoetin alfa), EpogenR (epoetin alfa)
If the Hgb level approaches or exceeds 11 g/dL,
|Drug||Dosing Regimen||Authorization Limit|
0.04 mg/kg IV or SC once a month
Conversion from another ESA:
dose once monthly based on the total weekly epoetin or
darbepoetin alfa dose at the time of conversion
For patient with CKD on dialysis:
Dose must be reduced or interrupted if the Hgb level approaches or exceeds 11 g/dL.
Continued treatment will be approved every 6 months or to member's renewal period,
whichever is sooner, upon receiving hematocrit (Hct), hemoglobin (Hgb),
transferrin saturation and ferritin values.
Documentation of transferrin saturation greater than or equal to 20% and
ferritin greater than or equal to 100 ng/mL within 60 days of the
request must be submitted prior to dose increase.
Additional dose escalations for patients who do not respond
adequately over a 12-week escalation period will not be approved.
Single use vials (preservative-free): 2 mg/0.5 mL, 3 mg/0.5 mL, 4 mg/0.5 mL, 5 mg/0.5 mL, and 6 mg/0.5 mL
Single use pre-filled syringes (preservative-free): 1 mg/0.5 mL, 2 mg/0.5 mL, 3 mg/0.5 mL, 4 mg/0.5 mL, 5 mg/0.5 mL, and 6 mg/0.5 mL
Multiple use vials (with preservative): 10 mg/mL and 20 mg/2 mL