Ferriprox — Blue Cross Blue Shield of Alabama

other FDA approved indication

Preferred products

ONE of the following:
- The patient has a diagnosis of transfusional iron overload with thalassemia syndromes
- OR transfusional iron overload with sickle cell disease or other anemias AND BOTH: patient does NOT have myelodysplastic syndrome AND does NOT have Diamond Blackfan anemia
- OR another FDA approved indication for the requested agent and route of administration OR another indication supported in compendia
AND patient has absolute neutrophil count (ANC) ≥ 1.5 X 10^9/L
AND if FDA approved indication: patient’s age is within FDA labeling OR there is support for age use
AND if brand Ferriprox requested: patient has tried and had inadequate response to generic deferiprone OR has intolerance or hypersensitivity to generic deferiprone not expected with brand OR has FDA labeled contraindication to generic not expected with brand OR there is support for brand over generic (compliance only accepted after trial of generic)
AND ONE of the following: tried and inadequate response to Exjade (deferasirox) or Jadenu (deferasirox), OR intolerance or hypersensitivity to Exjade or Jadenu, OR FDA labeled contraindication to BOTH Exjade and Jadenu
AND prescriber is a specialist or has consulted with one
AND patient will NOT use in combination with another iron chelating agent targeted in this program
AND patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND patient has had clinical benefit with the requested agent
AND patient has absolute neutrophil count (ANC) ≥ 1.5 X 10^9/L
AND prescriber is a specialist or has consulted with one
AND patient will NOT use in combination with another iron chelating agent targeted in this program
AND patient does NOT have any FDA labeled contraindications to the requested agent

12 months