CurrentCignaPolicy N/A

Erythropoiesis‑Stimulating Agents prior authorization (Epogen, Procrit, Retacrit)

Prior authorization form and requirements for coverage of epoetin alfa products (Epogen, Procrit, Retacrit) across clinical indications including anemia in CKD, cancer, MDS, myelofibrosis, HIV, and perioperative transfusion reduction; intended for providers submitting requests to Cigna Pharmacy Services.

Policy Summary

PayerCigna

PolicyErythropoiesis‑Stimulating Agents prior authorization (Epogen, Procrit, Retacrit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with clinical details (indication, hemoglobin, prior ESA use, iron status) via fax to 855-840-1678.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

855-840-1678fax number to submit completed form

5 business daysstandard response time

800-882-4462urgent request phone

Accredopreferred specialty pharmacy

Coverage Criteria and Indications

Policy Summary

PayerCigna

PolicyErythropoiesis‑Stimulating Agents prior authorization (Epogen, Procrit, Retacrit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with clinical details (indication, hemoglobin, prior ESA use, iron status) via fax to 855-840-1678.

SourceLink

On This Page

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Indication selection: Request must specify one of the listed diagnoses: CKD on dialysis; CKD not on dialysis; anemia due to myelosuppressive cancer chemotherapy; anemia associated with cancer not receiving myelosuppressive chemotherapy; AML/CML/other myeloid cancers; radiotherapy‑related anemia; myelodysplastic syndrome (MDS); myelofibrosis; HIV receiving zidovudine; reduction of allogeneic red blood cell transfusions for surgery; other (including athletic performance, acute blood loss, non‑anemic preoperative use)

Form provides checkboxes for each indication

CKD not on dialysis initial therapy criteria: For CKD not on dialysis, indicate whether this is initial therapy or the patient is currently receiving an ESA. If initial therapy: for patients 17 years or younger, hemoglobin must be 11 g/dL or less; for patients 18 years or older, hemoglobin must be 9.9 g/dL or less. Document current iron therapy status and, if not receiving iron, document adequacy of iron stores.≤ 11 g/dL (<=17 yrs); ≤ 9.9 g/dL (>=18 yrs)

Form requests hemoglobin, age category, iron therapy and adequacy of iron stores

Myelosuppressive chemotherapy criteria: For anemia due to myelosuppressive chemotherapy, document whether the patient is currently receiving myelosuppressive chemotherapy and whether it is considered non‑curative. If initial therapy, hemoglobin must be 9.9 g/dL or less. Document iron therapy status and adequacy as applicable.≤ 9.9 g/dL for initial therapy

Form asks chemotherapy status and curative intent

MDS, Myelofibrosis, or Zidovudine (HIV) criteria: For MDS, myelofibrosis, or zidovudine‑related anemia, indicate initial versus ongoing ESA use. If initial therapy, hemoglobin must be less than 10.0 g/dL. If hemoglobin criteria are not met, provide serum erythropoietin level; form captures whether serum EPO is 500 mU/mL or less. For MDS/myelofibrosis, the medication should be prescribed by or in consultation with a hematologist/oncologist. For myelofibrosis on current therapy, document response defined as hemoglobin ≥10 g/dL or an increase of ≥2 g/dL from pretreatment for continuation decisions.Hb <10.0 g/dL initial; serum EPO ≤500 mU/mL when applicable; response = Hb ≥10 g/dL or increase ≥2 g/dL

Form requests EPO level and specialist involvement; captures response criteria for continuation

Transfusion‑reduction (preoperative) criteria: For reduction of allogeneic red blood cell transfusions in patients undergoing elective surgery, document current hemoglobin (13 g/dL or less option), whether the patient is scheduled for elective surgery and if it is vascular or cardiac, and whether the patient is willing/able to donate autologous blood prior to surgery.Hb ≤ 13 g/dL

Form captures surgery type and autologous donation capability

Response and continuation criteria: For ongoing therapy or continuation requests, document treatment response: hemoglobin at least 10 g/dL OR an increase of at least 2 g/dL from pretreatment. Use these data to assess continued benefit of ESA therapy (applies particularly to myelofibrosis and other ongoing therapy assessments).Hb ≥ 10 g/dL OR increase ≥ 2 g/dL

Form includes questions to capture response for continuation

Billing and Diagnosis Codes

Billing code (J-code) — requester suppliesmixed

J-code (to be provided)

Field on form requesting J-code associated with the medication

Diagnosis code — requester suppliesICD-10

ICD10 (to be provided)

Field on form requesting ICD-10 diagnosis code

Hemoglobin thresholds — indication-specific

CKD not on dialysis (initial, age ≤17)Hemoglobin ≤11 g/dL

CKD not on dialysis (initial, age ≥18)Hemoglobin ≤9.9 g/dL

Myelosuppressive chemotherapy (initial)Hemoglobin ≤9.9 g/dL

MDS / Myelofibrosis / Zidovudine HIV (initial)Hemoglobin <10.0 g/dL

Transfusion reduction (preoperative)Hemoglobin ≤13 g/dL

Response/continuation thresholdHemoglobin ≥10 g/dL or increase ≥2 g/dL from pretreatment

Provider Actions, Documentation, and Submission

Prior Authorization

Prior authorization required — submit completed form via fax

Prior authorization is required for requests for Epogen, Procrit, or Retacrit. Submit a completed prior authorization form and include indication and relevant clinical details; fax the completed form to 855-840-1678 (standard response time is 5 business days; call 800-882-4462 for urgent requests).

Include indication, hemoglobin values, prior ESA use, iron status, and any relevant specialty consultation on the form.

Step Therapy

Prior trial questions — document prior Procrit use or intolerance

The form asks whether the patient has tried Procrit (or had intolerance/allergy), and this information may be used to document a prior trial when requesting Epogen.

Select whether patient has not tried Procrit, tried Procrit but it was ineffective, or had a significant allergy/adverse reaction and provide supporting details.

Documentation Required

Required documentation on PA form — include IDs, drug, labs, and clinical notes

Include complete patient and provider identifiers, medication and billing details, relevant labs, and supporting clinical notes with the PA request as indicated on the form.

Provider identifiers: Specialty, DEA/NPI/TIN.
Patient identifiers: Cigna ID, date of birth, address, phone.
Medication details: drug name (Epogen/Procrit/Retacrit), strength, dosing schedule, J-code, ICD-10 diagnosis, number of injections per month, expected duration, patient weight.
Facility/administration: facility name, tax ID, address, and site of administration.
Clinical data: indication, initial vs ongoing therapy, hemoglobin values per indication, iron therapy status and adequacy, serum erythropoietin if requested, chemotherapy status, prescriber specialty or hematology/oncology consultation when required.

Denial Risk

Site-of-care consideration — document least intensive appropriate setting

Some Cigna plans require that infusion of the medication occur in the least intensive, medically appropriate setting; the form asks the provider to indicate site of administration and whether the patient is a candidate for redirection to an alternate, less intensive setting and to provide medical necessity rationale if applicable.

Indicate planned administration site (home, physician office, hospital outpatient, other) on the form.
If redirection to an alternate setting is possible, document candidate status and provide medical necessity rationale when requested.

OpenPayer

Erythropoiesis‑Stimulating Agents prior authorization (Epogen, Procrit, Retacrit)

Coverage Criteria and Indications

Billing and Diagnosis Codes

Provider Actions, Documentation, and Submission

Definitions

Background