Patient is receiving treatment with zidovudine at a dose < 4200 mg/week Renewal: Patient meets both of the following: 3 months Endogenous erythropoietin levels < 500 mUnits/mL. Hemoglobin < 10 g/dL within the last two weeks Requires Hb < 11 g/dL within Anemia associated with myelodysplastic syndrome the last 2 weeks (Epogen, Procrit) Follow up iron studies Patient meets all of the following: showing member has Hemoglobin < 10 g/dL within 2 weeks prior to initiating therapy adequate iron to Recent erythropoietin < 500 mU/mL support erythropoiesis Anemia due to Chemotherapy in Patients with Cancer (Epogen, Procrit, Aranesp) Patient is currently receiving chemotherapy Patient meets all of the following: Hemoglobin < 10 g/dL within the 2 prior to starting therapy Documentation to support anemia is due to concomitant myelosuppressive chemotherapy Diagnosis of non-myeloid malignancy (e.g., solid tumor) Patient has a minimum of 2 additional months of planned chemotherapy upon initiation of therapy Additional information may be required on a case-by-case basis to allow for adequate review. Forteo For Patients who meet all of the following: Initial Approval: > 18 years of age Osteoporosis 2 years – Black box warning due to the potential risk of osteosarcoma, Forteo should not be used in Hypoparathyroidism – – patients at increased baseline risk for osteosarcoma (e.g., Paget’s disease of bone or 3 months (parathyroid unexplained elevations of alkaline phosphatase, open epiphyses, or prior external beam or hormone level, PTH – implant radiation therapy involving the skeleton). Forteo should only be prescribed for patients within 30 days) whom potential benefits outweigh potential risk. Renewal: 1 year For the treatment of osteoporosis in men and women who meet the following criteria:
Patient is receiving treatment with zidovudine at a dose < 4200 mg/week Patient meets both of the following: Endogenous erythropoietin levels < 500 mUnits/mL. Hemoglobin < 10 g/dL within the last two weeks Anemia associated with myelodysplastic syndrome (Epogen, Procrit) Patient meets all of the following: Hemoglobin < 10 g/dL within 2 weeks prior to initiating therapy Recent erythropoietin < 500 mU/mL Anemia due to Chemotherapy in Patients with Cancer (Epogen, Procrit, Aranesp) Patient is currently receiving chemotherapy Patient meets all of the following: Hemoglobin < 10 g/dL within the 2 prior to starting therapy Documentation to support anemia is due to concomitant myelosuppressive chemotherapy Diagnosis of non-myeloid malignancy (e.g., solid tumor) Patient has a minimum of 2 additional months of planned chemotherapy upon initiation of therapy Additional information may be required on a case-by-case basis to allow for adequate review. Renewal: 3 months Requires Hb < 11 g/dL within the last 2 weeks Follow up iron studies showing member has adequate iron to support erythropoiesis Forteo For Patients who meet all of the following: > 18 years of age Black box warning – due to the potential risk of osteosarcoma, Forteo should not be used in patients at increased baseline risk for osteosarcoma (e.g., Paget’s disease of bone or unexplained elevations of alkaline phosphatase, open epiphyses, or prior external beam or implant radiation therapy involving the skeleton). Forteo should only be prescribed for patients whom potential benefits outweigh potential risk. For the treatment of osteoporosis in men and women who meet the following criteria: Initial Approval: Osteoporosis – 2 years Hypoparathyroidism – 3 months (parathyroid hormone level, PTH – within 30 days) Renewal: 1 year
MMIC-PA-SMI-Guidelines.docx