Erythropoiesis-Stimulating Agents – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers ESAs (Aranesp, Epogen, Procrit, Retacrit; Mircera is limited/unproven for chemotherapy-related anemia) for specific indications — CKD (dialysis and non‑dialysis), certain cancer chemotherapy settings (generally non‑curative/palliative or if transfusion is refused), MDS, myelofibrosis, zidovudine‑ and HCV‑related anemia, and selected elective noncardiac/nonvascular preoperative use — and excludes/unproves use for curative chemotherapy, immediate substitution for transfusion, cardiac/vascular surgery, autologous donation, and specified higher hematocrit ranges. Key requirements include submission of a hematocrit within 30 days meeting strict thresholds (generally Hct <30% to initiate; chemo Hct ≤30%; dialysis continuation Hct <33%; MDS requires serum EPO ≤500 mU/mL), exclusion/confirmation of other anemia causes (e.g., iron/B12), documentation of normal iron stores for chemo, documented clinical response and time‑limited authorizations (typically ≤12 months, perioperative ≤3 months), and documented trial/failure or intolerance of Retacrit (with physician attestation) before Epogen/Procrit.