MedicaidPrior AuthMedium impact
Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)
Humana·SC, VA · Nephrology, Hematology, Internal Medicine·Medicaid
Effective date
Jan 1, 2022
We identified it
Jul 22, 2026
Summary
This is a revised Mircera (methoxy polyethylene glycol-epoetin beta) prior authorization policy for Medicaid in South Carolina and Virginia, effective January 1, 2022, with a revision date of July 22, 2026. The policy requires prior authorization for Mircera use in anemia of chronic kidney disease and establishes specific clinical criteria for initial approval (hemoglobin <10 g/dL, iron studies, exclusion of other anemia causes) and renewal (hemoglobin <11 g/dL or documented dose adjustment). The policy emphasizes the black box warning regarding cardiovascular risks and reinforces that targeting hemoglobin >11 g/dL is not recommended.
Action Required
Before submitting any Mircera claims for South Carolina or Virginia Medicaid members: (1) Billing team must verify prior authorization requirements are configured in the billing system for Mircera (methoxy polyethylene glycol-epoetin beta) injections as a pharmacy benefit requiring PA; (2) Ensure providers document the following in the medical record before claim submission: diagnosis of chronic kidney disease, most recent hemoglobin level (within 4 weeks, must be <10 g/dL for initial or <11 g/dL for renewal), iron studies (transferrin saturation ≥20% OR ferritin ≥100 ng/mL within 4 months), and confirmation that other causes of anemia have been ruled out; (3) For continuation/renewal requests, verify documentation of iron studies within the last 4 months and current hemoglobin levels; (4) Do not submit claims without prior authorization approval or they will be denied. Update PA request templates to align with the four initial criteria and two renewal criteria listed in this policy.