Subject: Anadrol-50 PA Policy 1087-A 01-2022

Drug

ANADROL-50  (oxymetholone)

Policy:

FDA-approved Indications
Anadrol-50 Tablets are indicated in the treatment of anemias caused by deficient red cell production.  Acquired aplastic anemia, congenital aplastic anemia, myelofibrosis and the hypoplastic anemias due to the administration of myelotoxic drugs often respond. Anadrol-50 Tablets should not replace other supportive measures such as transfusion, correction of iron, folic acid, vitamin B₁₂ or pyridoxine deficiency, antibacterial therapy and the appropriate use of corticosteroids. 

Compendial Uses
Cachexia associated with AIDS (HIV wasting)³ 

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:

• The requested drug is being prescribed for any of the following: A) Anemia due to deficient red cell production, (e.g., acquired aplastic anemia, congenital aplastic anemia, myelofibrosis, the hypoplastic anemias due to the administration of myelotoxic drugs, Fanconi’s anemia), B) Cachexia associated with acquired immunodeficiency syndrome (AIDS) (human immunodeficiency virus [HIV] wasting)

Place of Service:

Outpatient

The above policy is based on the following references:

1. Anadrol-50 [package insert]. Marietta, GA: Alaven Pharmaceuticals LLC; December 2006.
2. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021; Accessed December 7, 2021.
3. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed December 7, 2021.
4. Food and Drug Administration. Testosterone and other anabolic androgenic steroids (AAS): FDA statement – risks associated with abuse and dependence. Silver Spring, MD; 2016 Oct 25. Available at: https://wayback.archive-it.org/7993/20170111133941/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm526151.htm. Accessed December 2021

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 12, 2022