Epoetin Alfa (EPO) Guidelines and Form

The EPO usage guidelines we follow are based on U.S. Food and Drug Administration (FDA) recommendations. These guidelines are also in compliance with current recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI), with the goal of achieving a hemoglobin in the range of 11 - 12 percent or a hematocrit of 33 - 36 percent. Under the claims monitoring program:

  • Monitoring of the claims begins if the hematocrit reaches 11 percent (hemoglobin 33 g/dl) or the dose administered exceeds an average of 5,000 units per dose.
  • If the dosage is not reduced once the hemoglobin reaches 12.2 gm/dl and there is no medical documentation to support the higher dosage, BlueCross BlueShield of South Carolina will reduce payment to the level it would have been had the dosage been reduced by 25 percent.
  • In these instances, we will give the provider the appropriate notice and an opportunity to appeal our determination under the existing appeal regulations. Download the appeal form.