CurrentUnitedHealthcarePolicy Program Number 2024 P 1426-1

Jesduvroq (daprodustat) prior authorization for anemia due to chronic kidney disease in dialysis patients

Defines prior authorization criteria for Jesduvroq (daprodustat) for adults with anemia due to chronic kidney disease who have been receiving dialysis for at least four months. Applies to UnitedHealthcare Pharmacy clinical programs.

Policy Summary

PayerUnitedHealthcare

PolicyJesduvroq (daprodustat) prior authorization for anemia due to chronic kidney disease in dialysis patients

Policy CodePolicy Program Number 2024 P 1426-1

Change TypeNo material changes

Effective DateApr 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization demonstrating CKD-related anemia and at least four months of dialysis for initial approval; document positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12Authorization duration (initial & reauthorization)

>=4 monthsMinimum dialysis duration required before initiation

1Program type: Prior Authorization/Notification

Medical Necessity Criteria for Jesduvroq (daprodustat)

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Limitations of Use / Exclusions

Situations where Jesduvroq is not indicated or has not demonstrated benefit:

ANY of the following

Not shown to improve quality of life, fatigue, or patient well-being
Not indicated as a substitute for transfusion in patients requiring immediate correction of anemia
Not indicated for use in patients not on dialysis

What Providers Must Do / Watch For

Prior Authorization

Prior authorization required

Prior authorization/notification is required for Jesduvroq (daprodustat). Initial approvals are issued for 12 months and require a diagnosis of anemia due to chronic kidney disease plus documentation that the patient has been receiving dialysis for at least 4 months.

Approval duration: 12 months
Minimum dialysis duration before initiation: ≥ 4 months

Documentation Required

Documentation for reauthorization

For reauthorization, providers must document a positive clinical response to Jesduvroq therapy; reauthorizations are issued for 12 months when this criterion is met.

Denial Risk

Potential automated decisions

UnitedHealthcare may approve initial authorizations and reauthorizations based solely on prior claim or medication history, diagnosis codes, and/or claim logic; the use of automated approval and re-approval processes varies by program and therapeutic class.

Clinical and Program Background

Jesduvroq (daprodustat) is a hypoxia-inducible factor prolyl hydroxylase (HIF-PHI) inhibitor indicated for treatment of anemia due to chronic kidney disease in adults who have been receiving dialysis for at least four months.

Limitations of use include that Jesduvroq has not been shown to improve quality of life, fatigue, or patient well-being, and it is not indicated as a substitute for transfusion in patients requiring immediate correction of anemia or for patients who are not on dialysis.

Scope, Policy Identifiers, and Administrative Notes

Defines prior authorization criteria for Jesduvroq (daprodustat) for adults with anemia due to chronic kidney disease who have been receiving dialysis for at least four months. This policy applies to UnitedHealthcare Pharmacy clinical programs and establishes that prior authorization/notification is required; approvals for both initial therapy and reauthorization are issued for 12 months.

Providers must document the relevant diagnosis and meet the dialysis duration requirement for initial approval; reauthorization requires documentation of a positive clinical response to therapy. UnitedHealthcare may also approve initial or reauthorization requests based solely on prior claim/medication history, diagnosis codes, and/or claim logic, and use of automated approval processes varies by program.

Coverage may be affected by state mandates, federal regulatory requirements, and the member's specific benefit plan. Other UnitedHealthcare policies and utilization management programs may also apply. Program Number 2024 P 1426-1; Subject: Jesduvroq (daprodustat) prior authorization for anemia due to chronic kidney disease in dialysis patients.