[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-566894-105":53,"doc-detail-566894-en":120},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":113,"head_meta":115,"extra_data":117,"updated_unix":119},105,"en","erythropoiesis-stimulating-agents-policy-number-2026d0028y","Erythropoiesis-Stimulating Agents - Policy Number 2026D0028Y","","UnitedHealthcare® Commercial Medical Benefit Drug Policy outlines coverage criteria for erythropoiesis-stimulating agents (ESAs), listing Aranesp, Epogen, Mircera, Procrit, and Retacrit. Retacrit is the preferred ESA, with coverage dependent on diagnosis-specific requirements and therapy response. Epogen or Procrit coverage requires meeting preferred product criteria or documented failure/contraindication/intolerance to Retacrit, with physician attestation. Criteria are detailed for anemia due to chronic kidney disease (dialysis and non-dialysis) and anemia due to cancer chemotherapy, including hematocrit thresholds, contraindications, and authorization duration limits.",{"@graph":63,"@context":112},[64,80,95],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/erythropoiesis-stimulating-agents-policy-number-2026d0028y/566894/",4,{"url":78,"name":59,"@type":81,"author":82,"headline":59,"publisher":85,"fileFormat":88,"inLanguage":57,"description":61,"dateModified":89,"datePublished":89,"encodingFormat":88,"isAccessibleForFree":90,"interactionStatistic":91},"DigitalDocument",{"name":83,"@type":84},"Dusta123","Person",{"url":68,"name":86,"@type":87},"DocShare","Organization","application/pdf","2026-10-13",true,{"@type":92,"interactionType":93,"userInteractionCount":4},"InteractionCounter",{"@type":94},"ViewAction",{"@type":96,"mainEntity":97},"FAQPage",[98,104,108],{"name":99,"@type":100,"acceptedAnswer":101},"Which erythropoiesis-stimulating agents (ESAs) are covered under this policy?","Question",{"text":102,"@type":103},"The policy addresses Aranesp (darbepoetin alfa), Epogen (epoetin alfa), Mircera (MPG-epoetin beta), Procrit (epoetin alfa), and Retacrit (epoetin alfa).","Answer",{"name":105,"@type":100,"acceptedAnswer":106},"Why is Retacrit considered the preferred ESA product?",{"text":107,"@type":103},"Retacrit is the preferred ESA product, and coverage depends on diagnosis-specific coverage criteria; prior authorization is not required for Retacrit under the stated terms.",{"name":109,"@type":100,"acceptedAnswer":110},"What hematocrit thresholds apply for ESA coverage in patients receiving dialysis?",{"text":111,"@type":103},"For initial therapy, ESA coverage requires hematocrit less than 30% at initiation; for continuation, hematocrit must remain less than 33%.","https://schema.org",{"og:url":78,"og:type":114,"og:title":59,"og:site_name":86,"og:description":61},"article",{"robots":116,"canonical":78},"index,follow",{"doc_id":118,"site_id":56},566894,1791864162,{"code":4,"msg":5,"data":121},{"doc_id":118,"user_id":122,"nickname":83,"user_avatar":123,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":124,"file_id":125,"file_url":126,"file_type":127,"file_size":128,"view_count":4,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":35,"language":129,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":130,"faqs":131,"seo_title":132,"seo_description":61,"update_tm":119,"read_time":133},962093541925,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","UnitedHealthcare® Commercial Medical Benefit Drug Policy  \nErythropoiesis-Stimulating Agents  \nPolicy Number: 2026D0028Y  \nEffective Date: April 1, 2026 􀃂 Instructions for Use  \nTable of Contents Page  \nCoverage Rationale ............................................................ 1  \nApplicable Codes ................................................................ 5  \nBackground......................................................................... 5  \nBenefit Considerations ........................................................ 6  \nClinical Evidence................................................................. 6  \nU.S. Food and Drug Administration ................................... 13  \nCenters for Medicare and Medicaid Services ..................... 14  \nReferences ....................................................................... 14  \nPolicy History/Revision Information ................................... 16  \nInstructions for Use ........................................................... 16  \n\n| Community Plan Policy |\n| --- |\n| •  Erythropoiesis-Stimulating Agents |\n|  |\n| Medicare Advantage Policy |\n| •  Medicare Part B Step Therapy Programs |\n\nCoverage Rationale  \n􀃂 See Benefit Considerations  \nThis policy addresses the following erythropoiesis-stimulating agents (ESAs):  \n Aranesp® (darbepoetin alfa)  \n Epogen® (epoetin alfa)  \n Mircera® [methoxy polyethylene glycol-epoetin beta (MPG-epoetin beta)]  \n Procrit® (epoetin alfa)  \n Retacrit ™ (epoetin alfa)  \nPreferred Product  \nMedical Necessity Plans  \nRetacrit is the preferred ESA product. Coverage for Retacrit is contingent on the coverage criteria in the DiagnosisSpecific Criteria section. Prior authorization is not required.  \nCoverage for Epogen or Procrit is contingent on the Preferred Product Criteria in this section and the coverage criteria in the Diagnosis-Specific Criteria section. In order to continue coverage, members already on Epogen or Procrit will be required to change therapy to Retacrit unless they meet the criteria below.  \nPreferred Product Criteria (For Medicare reviews, refer to the CMS section. *)  \nTreatment with Epogen or Procrit is medically necessary for the indications specified in this policy when one the criteria below are met:  \n Both of the following:  \no History of a trial of adequate dose and duration of Retacrit, resulting in minimal clinical response; and  \no Physician attests that, in their clinical opinion, the clinical response would be expected to be superior than experienced with Retacrit  \nor  \n Both of the following:  \no History of failure, contraindication, or intolerance to Retacrit; and  \no Physician attests that, in their clinical opinion, the same failure, contraindication, or intolerance would not be expected to occur with Epogen or Procrit  \nNon-Medical Necessity Plans  \nRetacrit, Epogen, or Procrit is to be approved contingent on the coverage criteria in the Diagnosis-Specific Criteria section.  \nDiagnosis-Specific Criteria  \n“ESAs” will be used to refer to all erythropoiesis stimulating agents, unless otherwise specified.  \nFor the purposes of the Coverage Rationale , all hematocrit (Hct) values are either pretreatment (for the first 4-6 weeks of therapy) or obtained during treatment to assess ongoing titration and safety.  \nAnemia Due to Chronic Kidney Disease  \nPatients Receiving Dialysis  \nESAs are proven and medically necessary for the treatment of anemia of chronic kidney disease (CKD) when the following criteria are met:  \n For initial therapy, all of the following:  \no Patient is on dialysis; and  \no Hematocrit is less than 30% at initiation of therapy; and  \no Patient does not have evidence of other causes of anemia (e.g. , iron deficiency, hemolysis, vitamin B12 deficiency); and  \no Initial authorization will be for no more than 12 months  \n For continuation of therapy, all of the following:  \no If the request is for Epogen or Procrit, patient meets the criteria in the Preferred Product Criteri","cbCaiaqPjiNVcmYX","https://ap.wps.com/l/cbCaiaqPjiNVcmYX","pdf",452256,"English","# Coverage Rationale\n## Preferred Product\n## Preferred Product Criteria\n## Non-Medical Necessity Plans\n## Diagnosis-Specific Criteria\n### Anemia Due to Chronic Kidney Disease\n#### Patients Receiving Dialysis\n#### Patients Not Receiving Dialysis\n### Anemia Due to Cancer Chemotherapy","[{\"question\":\"Which erythropoiesis-stimulating agents (ESAs) are covered under this policy?\",\"answer\":\"The policy addresses Aranesp (darbepoetin alfa), Epogen (epoetin alfa), Mircera (MPG-epoetin beta), Procrit (epoetin alfa), and Retacrit (epoetin alfa).\"},{\"question\":\"Why is Retacrit considered the preferred ESA product?\",\"answer\":\"Retacrit is the preferred ESA product, and coverage depends on diagnosis-specific coverage criteria; prior authorization is not required for Retacrit under the stated terms.\"},{\"question\":\"What hematocrit thresholds apply for ESA coverage in patients receiving dialysis?\",\"answer\":\"For initial therapy, ESA coverage requires hematocrit less than 30% at initiation; for continuation, hematocrit must remain less than 33%.\"}]","Erythropoiesis-Stimulating Agents - Policy Number 2026D0028Y | PDF",6]