Epogen, Procrit, or Retacrit (epoetin alfa) Non-oncology

Epoetin alfa (Epogen/Procrit/Retacrit) is covered only for FDA‑approved non‑oncology indications—anemia of CKD (on or off dialysis), zidovudine‑associated anemia in HIV, and to reduce allogeneic transfusion in elective nonvascular/noncardiac surgery—oncology uses are excluded. Coverage requires documentation of diagnosis, specific hemoglobin/EPO thresholds (e.g., initial CKD adult Hgb <10 g/dL; ESA‑treated thresholds ~<11.5–12.0 g/dL; surgical Hgb ≤13.0 g/dL; or EPO ≤500 mU/mL for zidovudine cases), evidence of adequate iron stores or current iron therapy, current zidovudine for that indication, surgical details when applicable, and approvals are for 12 months (1 month for surgery).

"Patient age to apply pediatric versus adult hemoglobin thresholds (documentation of date of birth or age)."

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