Prior Authorization : Preferred Drug List

Erythropoiesis Stimulating Proteins

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Jesduvroq

Jesduvroq requires clinical PA.

PA requests for Jesduvroq must be completed, signed, and dated by the prescriber. PA requests for Jesduvroq must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Jesduvroq may be submitted may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Jesduvroq

The clinical criteria for approval of a PA request for Jesduvroq are all of the following:

• The member has anemia due to chronic kidney disease.
• The member has been receiving dialysis for at least the previous four months and will continue to receive dialysis during treatment with Jesduvroq.
• The member does not have uncontrolled hypertension.
• The member has taken two preferred erythropoiesis stimulating proteins and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why Jesduvroq is being requested.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Jesduvroq. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

Initial and Renewal PA Requests for Jesduvroq

If the clinical criteria for Jesduvroq are met, initial PA requests may be approved for up to 183 days. Renewal PA requests may be approved for up to 365 days.

All renewal PA requests require the member to be adherent with the prescribed treatment regimen.