CurrentGeorgia Department of Community HealthPolicy N/A

Erythropoiesis-stimulating agents prior authorization

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Prior authorization requirements and coverage criteria for erythropoiesis-stimulating agents (Epogen, Retacrit, Aranesp, Mircera, Procrit) for Georgia Medicaid Fee-for-Service providers and members.

Policy Summary

PayerGeorgia Department of Community Health

PolicyErythropoiesis-stimulating agents prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests via the Georgia Health Partnership portal when the medication is administered in a physician office or clinic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+ESAs named

AllPrior auth required

VariesAuth length

OptumRxPA vendor

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentGeorgia Department of Community HealthPolicy N/A

Erythropoiesis-stimulating agents prior authorization

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Prior authorization requirements and coverage criteria for erythropoiesis-stimulating agents (Epogen, Retacrit, Aranesp, Mircera, Procrit) for Georgia Medicaid Fee-for-Service providers and members.

Policy Summary

PayerGeorgia Department of Community Health

PolicyErythropoiesis-stimulating agents prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests via the Georgia Health Partnership portal when the medication is administered in a physician office or clinic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5+ESAs named

AllPrior auth required

VariesAuth length

OptumRxPA vendor

Epogen and Retacrit — Approvals

Approvable when ANY one of the following diagnoses/conditions is met and hemoglobin or endogenous erythropoietin thresholds apply as specified:

Epogen/Retacrit indications: Anemia associated with chronic kidney disease (CKD) (including patients on dialysis and not on dialysis) who are treatment-naïve with a hemoglobin level of < 12 g/dL or treatment-experienced with a hemoglobin level of < 11 g/dL; anemia associated with zidovudine in members on doses of < 4,200 mg/week with an endogenous erythropoietin level of < 500 mU/ml; anemia in non-myeloid malignancies caused by myelosuppressive chemotherapy who are treatment-naïve with a hemoglobin level of < 12 g/dL or treatment-experienced with a hemoglobin level of < 11 g/dL; to reduce the need for blood transfusions in anemic participants scheduled to undergo elective surgery (excluding cardiac, cosmetic, or vascular surgery) who are unwilling to donate autologous blood with a hemoglobin level of > 10 g/dL to < 13 g/dL; anemia associated with myelodysplastic syndrome with an endogenous erythropoietin level of < 500 mU/ml; anemia due to ribavirin in members who did not experience an improvement in hemoglobin level with ribavirin dose reduction and with a hemoglobin level of < 10 g/dL

Aranesp — Approval

Approvable when ALL of the following are true:

Aranesp preconditions: Member has an allergy to benzyl alcohol or albumin, or intolerable side effects to the preferred products, Epogen and Procrit, that are not expected to occur with Aranesp

Aranesp indications: One of the following diagnoses: anemia associated with chronic kidney disease (CKD) (including patients on dialysis and not on dialysis) who are treatment-naïve with a hemoglobin level of < 12 g/dL or treatment-experienced with a hemoglobin level of < 11 g/dL; anemia in non-myeloid malignancies caused by myelosuppressive chemotherapy who are treatment-naïve with a hemoglobin level of < 12 g/dL or treatment-experienced with a hemoglobin level of < 11 g/dL; anemia associated with myelodysplastic syndrome with an endogenous erythropoietin level of < 500 mU/ml; anemia due to ribavirin in members who did not experience an improvement in hemoglobin level with ribavirin dose reduction and with a hemoglobin level of < 10 g/dL

Mircera — Approval

Approvable when ALL of the following are true:

Mircera preconditions: Member has an allergy to benzyl alcohol or albumin, or inadequate response to Epogen or Procrit

Mircera indications: Anemia associated with chronic kidney disease (CKD) in adult members (on dialysis and not on dialysis) who are treatment-naïve with a hemoglobin level of < 12 g/dL or treatment-experienced with a hemoglobin level of < 11 g/dL; pediatric members 5 to 17 years of age with CKD on hemodialysis who are converting after hemoglobin level was stabilized with an erythropoietin-stimulating agent (ESA)

Procrit — Approval

Approvable when the following administrative requirement is met:

Procrit precondition: Prescriber submits a written letter of medical necessity stating the reasons the preferred products, Epogen and Retacrit, are not appropriate for the member

Use of erythropoiesis‑stimulating agents to reduce transfusion need in patients scheduled for elective surgery is excluded for elective cardiac, cosmetic, and vascular surgery. The policy allows perioperative ESA use for other elective surgical procedures only when the member is unwilling to donate autologous blood and the hemoglobin is between > 10 g/dL and < 13 g/dL as specified for the blood‑conservation indication.

Aranesp and Mircera are not first‑line in this policy and require documented justification before approval. Specifically, both agents are approvable only when the member has a documented allergy to benzyl alcohol or albumin or a documented intolerance or inadequate response to the preferred agents (Epogen, Retacrit, Procrit) as described in the criteria. Absence of documentation of allergy/intolerance or inadequate response to preferred products may result in denial of requests for Aranesp or Mircera.

Prior authorization, submission, and documentation requirements

Prior Authorization

Prior authorization required for all ESAs

All erythropoiesis‑stimulating agents (ESAs) require prior authorization. If the medication is administered in a physician office or clinic, submit the coverage request via the Registered User portion of the Georgia Health Partnership portal (www.mmis.georgia.gov/portal) to request coverage from Physician Services.

Step Therapy

Use preferred agents first; Aranesp/Mircera require documented intolerance or inadequate response

Preferred agents (Epogen, Retacrit, Procrit) must be used first-line. Aranesp and Mircera are approvable only when the member has documented allergy/intolerance to benzyl alcohol or albumin or has an inadequate or intolerable response to the preferred products.

Aranesp: member must have an allergy to benzyl alcohol or albumin, or intolerable side effects to Epogen and Procrit not expected to occur with Aranesp (and meet one of the listed diagnoses).
Mircera: member must have an allergy to benzyl alcohol or albumin, or inadequate response to Epogen or Procrit (and meet one of the listed diagnoses).
Procrit: considered a preferred agent but requires additional administrative documentation (see Procrit block).

Documentation Required

Submission and documentation via GHP portal; Procrit requires LOMN

When the ESA will be administered in a physician office/clinic, providers must request coverage through the Registered User portion of the Georgia Health Partnership website (www.mmis.georgia.gov/portal). For Procrit, include the required written letter of medical necessity with the submission.

Submit office‑administered medication requests via the Georgia Health Partnership portal (Physician Services).
Attach the prescriber’s written letter of medical necessity for Procrit explaining why Epogen and Retacrit are not appropriate.

Denial Risk

Diagnostic and lab criteria must be documented

Requests must meet the diagnosis‑specific and hemoglobin or endogenous erythropoietin thresholds listed for coverage (for example, CKD anemia: treatment‑naïve Hb < 12 g/dL or treatment‑experienced Hb < 11 g/dL; zidovudine‑associated or myelodysplastic syndrome: endogenous erythropoietin < 500 mU/ml; ribavirin‑related anemia: Hb < 10 g/dL). Requests that do not meet these criteria are at risk for denial.

CKD and chemotherapy‑associated anemia thresholds: treatment‑naïve Hb < 12 g/dL; treatment‑experienced Hb < 11 g/dL.
Endogenous erythropoietin threshold for certain indications: < 500 mU/ml.
Ribavirin‑related anemia: Hb < 10 g/dL after dose reduction failed.

Denial Risk

Document intolerance/allergy or inadequate response for Aranesp and Mircera

If approval for Aranesp or Mircera is requested, providers must document the member’s allergy, intolerance, or inadequate response to preferred products; failure to provide this documentation may result in denial.

Aranesp: document allergy to benzyl alcohol or albumin, or intolerable side effects to Epogen/Procrit not expected with Aranesp.
Mircera: document allergy to benzyl alcohol or albumin, or inadequate response to Epogen/Procrit.

Documentation Required

Include letter of medical necessity for Procrit

Procrit requests require a prescriber‑submitted written letter of medical necessity explaining why the preferred products Epogen and Retacrit are not appropriate for the member; absence of this letter can lead to denial.

Background on erythropoiesis-stimulating agents

Erythropoiesis‑stimulating agents (ESAs) are used to treat anemia across several clinical contexts addressed by this policy. Covered indications include anemia associated with chronic kidney disease (CKD) (both dialysis and nondialysis patients), anemia related to myelosuppressive chemotherapy in non‑myeloid malignancies, anemia associated with zidovudine, myelodysplastic syndrome, and anemia due to ribavirin. Coverage decisions are tied to diagnosis and laboratory thresholds: for CKD and chemotherapy‑related anemia the hemoglobin thresholds differentiate treatment‑naïve (Hb < 12 g/dL) from treatment‑experienced (Hb < 11 g/dL) members; certain indications (zidovudine‑associated anemia and myelodysplastic syndrome) require an endogenous erythropoietin level < 500 mU/ml; and ribavirin‑related anemia requires Hb < 10 g/dL after failed dose reduction.

Definitions and term thresholds

inv-16: Treatment-naïve vs treatment-experienced — definition distinctions and related hemoglobin thresholds

Definition — treatment-naïveMembers who have not previously received ESA therapy; approval threshold: hemoglobin < 12 g/dL

Definition — treatment-experiencedMembers with prior ESA exposure; approval threshold: hemoglobin < 11 g/dL

Application — clinical indicationsThresholds apply across CKD and chemotherapy-associated anemia indications as specified in the policy

inv-17: Endogenous erythropoietin level — definition for zidovudine-associated anemia and myelodysplastic syndrome approvals

Definition — zidovudine-associated anemia & MDS criterionApproval requires endogenous erythropoietin level < 500 mU/ml for anemia associated with zidovudine and for myelodysplastic syndrome

Numeric threshold sourcePolicy specifies endogenous erythropoietin < 500 mU/ml as the required lab value for these indications

Associated product approvalsThis endogenous EPO threshold is referenced in criteria for Epogen/Retacrit and Aranesp approvals for the listed indications

Erythropoiesis-stimulating agents prior authorization

Sign up for all Georgia Department of Community Health policy alerts

Erythropoiesis-stimulating agents prior authorization

Sign up for all Georgia Department of Community Health policy alerts

Coverage criteria for erythropoiesis-stimulating agents

Clinical thresholds and coding-relevant values

Prior authorization, submission, and documentation requirements

Background on erythropoiesis-stimulating agents

Definitions and term thresholds