Intravenous Iron Therapy

Feraheme^® (Ferumoxytol) Approval Criteria:

• An FDA approved indication of 1 of the following:
• a.     Iron deficiency anemia (IDA); or
• b.     IDA with chronic kidney disease (CKD); and
• Documented lab results verifying IDA; and
• Documentation of intolerance or inadequate response to oral iron therapy after at least 3 months at recommended dosing; and
• Prescriber must verify the member does not have a previous history of allergic reaction to any intravenous iron medications; and
• A recent, failed trial of Infed^® (iron dextran) or Venofer^® (iron sucrose) or a patient-specific, clinically significant reason why the member cannot utilize Infed^® and Venofer^® must be provided.

Injectafer^® (Ferric Carboxymaltose) Approval Criteria:

• An FDA approved indication of 1 of the following:
• a.     Iron deficiency anemia (IDA); or
• b.     IDA in patients with non-dialysis dependent chronic kidney disease (CKD); and
• Documented lab results verifying IDA; and
• Documentation of intolerance or inadequate response to oral iron therapy after at least 3 months at recommended dosing; and
• A recent, failed trial of Infed^® (iron dextran) or Venofer^® (iron sucrose) or a patient-specific, clinically significant reason why the member cannot utilize Infed^® and Venofer^® must be provided.

Monoferric^® (Ferric Derisomaltose) Approval Criteria:

• An FDA approved indication of 1 of the following:
• a.     Iron deficiency anemia (IDA); or
• b.     IDA in patients with non-dialysis dependent chronic kidney disease (CKD); and
• Documented lab results verifying IDA; and
• Documentation of intolerance or inadequate response to oral iron therapy after at least 3 months at recommended dosing; and
• A recent, failed trial of Infed^® (iron dextran) or Venofer^® (iron sucrose) or a patient-specific, clinically significant reason why the member cannot utilize Infed^® and Venofer^® must be provided.