Epogen®, Procrit®, Retacrit® (epoetin alfa) Injection Non-oncology

Epoetin alfa (Epogen/Procrit/Retacrit) is covered only for FDA‑approved non‑oncology indications—anemia of CKD (dialysis and non‑dialysis), zidovudine‑associated anemia in HIV, and pre‑operative reduction of allogeneic transfusion for elective nonvascular, noncardiac surgery—and oncology indications are excluded. Coverage requires meeting specific lab and documentation criteria (Hb thresholds: <10.0 g/dL for adults with non‑dialysis CKD and for zidovudine‑associated anemia [≤11.0 g/dL if <18 years]; Hb ≤12.0 g/dL if already receiving an ESA; Hb ≤13.0 g/dL for the surgical indication; serum erythropoietin ≤500 mU/mL as an alternative for zidovudine cases), evidence of adequate iron stores or current iron therapy, proof of current zidovudine use when applicable, surgical documentation that the procedure is elective/nonvascular/noncardiac and the patient cannot/will not donate autologous blood, with approvals of 1 month for surgery and 12 months for other indications (IV route recommended for hemodialysis).