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Epoetin Alfa (Epogen, Procrit, Retacrit) (Revised)
Act
by Jan 1, 2025
Effective date
Jan 1, 2025
Identified
Jul 22, 2026
Summary
Humana has revised its Epoetin Alfa (Epogen, Procrit, Retacrit) prior authorization policy effective January 1, 2025, establishing unified clinical criteria across Medicare and Medicaid (South Carolina and Virginia) for seven anemia indications. The policy requires prior authorization for all three products, specifies preferred vs. non-preferred product hierarchies with step-therapy requirements, and mandates documentation of hemoglobin levels, iron stores, and exclusion of other anemia causes before approval.
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What to do
by Jan 1, 2025 · 7 steps
01Billing and clinical teams must implement prior authorization requirements for all Epoetin Alfa claims (J7171, J7173, J7174) across Medicare Part B, Medicare Part D, and Medicaid (SC/VA) members.
02Update billing system to enforce.
03Step-therapy protocol requiring documented inadequate response to preferred products (Retacrit/Procrit for Part B; Retacrit for Part D) for at least 2 consecutive months before approving non-preferred products.
04Mandatory clinical documentation collection including hemoglobin/hematocrit levels (within 4 weeks), iron studies (transferrin saturation ≥20% OR ferritin ≥100 ng/mL within 4 months), and exclusion of alternative anemia causes (iron/B12/folate deficiency, hemolysis, bleeding) BEFORE claim submission.
05Providers must document specific anemia indication (CKD, HIV/AZT, chemotherapy, pre-surgical, MDS, hepatitis C, or RA treatment) on all requests.
06For continuation therapy, update renewal criteria to require current hemoglobin documentation and iron store verification within 4 months.
07Train all billing staff, coders, and provider liaisons on new documentation requirements.
If missed: Failure to obtain prior authorization or provide required documentation will result in claim denials.
Codes mentioned
J7171J7173J7174
Original notice
Epoetin Alfa (Epogen, Procrit, Retacrit) (Revised)
mcp.humana.com · Always check the source before changing claims.
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