CurrentColorado Rocky Mountain Health PlansPolicy N/A

Jesduvroq (daprodustat) prior authorization

Prior authorization criteria and reauthorization rules for Jesduvroq (daprodustat) for treatment of anemia due to chronic kidney disease in adults receiving dialysis; applies to UnitedHealthcare Pharmacy Clinical Pharmacy Programs enrollees covered under Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyJesduvroq (daprodustat) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization: approve when patient has anemia due to CKD and has been receiving dialysis for at least four months; issue authorization for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

>=4 morequired dialysis

1/2024P&T approval

2024 P 1426-1program id

Coverage Criteria for Jesduvroq (daprodustat)

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inv-01: Initial Authorization — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial Authorization Criteria: a) Diagnosis of anemia due to chronic kidney disease (CKD); AND b) Patient has been receiving dialysis for at least four months.at least four months

Authorization will be issued for 12 months.

inv-02: Reauthorization — Covered when the following are met

Covered when the following are met

Reauthorization Criteria: Documentation of positive clinical response to Jesduvroq (daprodustat) therapy.

Authorization will be issued for 12 months.

Jesduvroq (daprodustat) is not indicated as a substitute for transfusion in patients who require immediate correction of anemia. It is also not indicated for use in patients who are not on dialysis. These limitations mean Jesduvroq should not be used when rapid hemoglobin correction via transfusion is clinically required or when the patient does not meet the policy’s dialysis requirement.

Use of Jesduvroq to improve patient-reported outcomes such as quality of life, fatigue, or overall patient well‑being is not established. The evidence does not support coverage when the primary intent of therapy is symptomatic improvement in these domains.

Initial Therapy Criteria

inv-12: Initial Therapy — detailed initial coverage criteria

Initial coverage criteria

Initial Therapy: Diagnosis of anemia due to CKD AND patient has been receiving dialysis for at least four months.at least four months

12-month authorization will be issued.

Reauthorization / Continuation Criteria

inv-13: Reauthorization/Continuation — requires evidence of clinical benefit for ongoing approval

Reauthorization requires evidence of benefit

Continuation: Documentation of positive clinical response to Jesduvroq (daprodustat) therapy is required for continued approval.

Authorization will be issued for 12 months upon approval.

Provider Actions and Documentation Requirements

Prior Authorization

Initial authorization requirements

Prior Authorization Required: Jesduvroq (initial authorization) — prior authorization is required. Authorization will be issued for 12 months when ALL of the following are met.

Diagnosis: anemia due to chronic kidney disease (CKD).
Dialysis: patient has been receiving dialysis for at least four months.

Documentation Required

Documentation for reauthorization and automated approvals

Documentation for reauthorization and automated re-approval — providers must document a positive clinical response to Jesduvroq for reauthorization. Authorization for reauthorization will be issued for 12 months. Note: UnitedHealthcare (programs may vary) may approve initial or reauthorization based solely on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic using automated approval or re-approval processes.

Reauthorization criterion: documentation of positive clinical response to Jesduvroq therapy.
Automated approval: approvals or re-approvals may be granted based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; use of automated processes varies by program.

Denial Risk

Denial may result if patient does not have required diagnosis or dialysis duration

Denial Risk — coverage may be denied if required criteria are not met.

Absence of required diagnosis (anemia due to CKD) may result in denial.
If the patient has not been on dialysis for at least four months, authorization may be denied.

Background

Daprodustat (trade name Jesduvroq) is a hypoxia‑inducible factor prolyl hydroxylase (HIF PH) inhibitor indicated for the treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis. Per the policy, patients must have been on dialysis for at least four months prior to initiation, and authorizations are issued for 12 months. The manufacturer’s limitations note that Jesduvroq has not been shown to improve quality of life, fatigue, or patient well‑being and is not a substitute for transfusion or for patients not on dialysis.