Traditional MedicarePrior AuthHigh impact
Aranesp® (darbepoetin alfa) (Revised)
Humana·SC · Nephrology, Oncology, Hematology +1 more·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 22, 2026
Summary
This is a revised Aranesp (darbepoetin alfa) prior authorization policy for Humana Medicare and Medicaid (South Carolina) effective January 1, 2025. The policy establishes clinical criteria for coverage across three indications: anemia of chronic kidney disease, anemia in chemotherapy-treated cancer members, and anemia in myelodysplastic syndromes. Key requirements include baseline hemoglobin/hematocrit thresholds, iron store evaluation, exclusion of other anemia causes, and step therapy (inadequate response to Retacrit/Procrit for 2+ months) before approval. Continuation therapy requires documented iron stores and ongoing hemoglobin monitoring.
Action Required
By January 1, 2025: Billing team must implement prior authorization requirements for all Aranesp (darbepoetin alfa) claims in the Humana billing system for Medicare Part D, Medicare Part B, and Medicaid (South Carolina) members. Update claim submission workflow to require prior auth submission with documented evidence of: (1) qualifying diagnosis (CKD, chemotherapy-induced anemia, or MDS); (2) baseline hemoglobin <10 g/dL (or <12 g/dL for MDS) within 4 weeks; (3) iron store evaluation (transferrin saturation ≥20% OR ferritin ≥100 ng/mL) within 4 months; (4) documentation of ruled-out alternative causes of anemia; and (5) for initial authorization only—documented inadequate response to Retacrit or Procrit therapy for 2 consecutive months with dose adjustment (exception: Medicare Part B continuation within 365 days). For renewal requests, require current hemoglobin documentation or dose adjustment records within 4 weeks. Update provider ordering screens and prior auth submission templates to capture these criteria. Billing team must flag claims lacking step therapy documentation for denial under Medicare Part D and Medicare Part B (non-continuation). Train front desk and billing staff to collect required lab results and clinical documentation before submission. Failure to obtain prior authorization will result in claim denials.