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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.

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.

Last Modified on Jan 19, 2022
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