Erythropoiesis Stimulating Agents (CPB 0195, reviewed 2026-01-20)

IMMEDIATELY: Billing team must implement precertification workflow for all Aetna commercial members requesting ESA medications (Aranesp, Epogen, Procrit, Retacrit, Mircera). Update billing system and EMR to require prior authorization BEFORE dispensing—do NOT submit claims without documented precertification approval. Staff must call (866) 752-7021 or fax (888) 267-3277 for all ESA precertification requests. Verify the following documentation is present before submission: (1) pretreatment hemoglobin level (excluding recent transfusion values); (2) serum transferrin saturation (TSAT) ≥20% within prior 3 months OR confirmation patient is receiving iron therapy; (3) confirmation no concomitant ESAs or HIF-PHI drugs are being used; (4) specific clinical indication with applicable hemoglobin threshold met (Initial: <10 g/dL for most indications; Continuation: <12 g/dL). For surgery cases, document elective noncardiac/nonvascular procedure with pretreatment Hgb ≤13 g/dL. For HIV/zidovudine cases, document serum EPO <500 mU/mL. For myelofibrosis cases, document both Hgb <10 g/dL AND EPO <500 mU/mL. Update encounter forms and provider templates to include these verification checkpoints. Claims submitted without precertification approval will be denied. Communicate policy to all prescribing providers immediately.