Mircera® (methoxy polyethylene glycol-epoetin beta) Injection

Covered: Mircera is covered for anemia of chronic kidney disease in adults (on dialysis or not) and for pediatric patients 3 months–17 years only when converting from another ESA after hemoglobin stabilization; prefilled syringes cannot be used for partial dosing so pediatric patients needing <30 mcg are excluded. Key requirements: approval (12 months) requires documented dialysis status, adequate iron stores or ongoing iron therapy, age verification, specified hemoglobin thresholds (initial non‑ESA adults Hgb <10.0 g/dL; patients already on an ESA must meet the policy’s Hgb criteria up to 12.0 g/dL), and adherence to the policy’s weight‑based dosing, conversion dosing, and route‑of‑administration rules (especially for children <6 years).

"Documentation of iron status: evidence of adequate iron stores or documentation that the patient is currently receiving iron therapy."