Ferriprox (deferiprone) — Blue Cross Blue Shield of Illinois

Preferred products

• generic deferiprone
• Exjade (deferasirox)
• Jadenu (deferasirox)

Initial criteria

• 1. The patient has tried and had an inadequate response to a generic deferiprone OR a generic deferiprone was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR the patient has an intolerance or hypersensitivity to a generic deferiprone that is not expected to happen with the requested agent OR the patient has an FDA labeled contraindication to a generic deferiprone that is not expected to happen with the requested agent OR a generic deferiprone is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm OR a generic deferiprone agent is not in the best interest of the patient based on medical necessity OR the patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as generic deferiprone and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR there is support for the use of the requested brand agent over a generic deferiprone (NOTE: patient compliance will only be accepted after a trial of a generic).
• 2. ONE of the following: A. BOTH of the following: (1) the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR an associated condition related to stage four advanced, metastatic cancer, AND (2) the use of the requested agent is consistent with best practices for treatment of stage four advanced, metastatic cancer or associated condition supported by peer‑reviewed literature and FDA approval; OR B. The patient is currently being treated with the requested agent and is stable on therapy; OR C. The patient has tried and had an inadequate response to Exjade (deferasirox) or Jadenu (deferasirox); OR D. Exjade (deferasirox) or Jadenu (deferasirox) was discontinued due to lack of efficacy, diminished effect, or adverse event; OR E. The patient has an intolerance or hypersensitivity to Exjade or Jadenu; OR F. The patient has an FDA labeled contraindication to BOTH Exjade and Jadenu; OR G. Exjade or Jadenu is expected to be ineffective or cause barriers/adverse effects as defined; OR H. Exjade or Jadenu is not in the best interest of the patient based on medical necessity; OR I. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as Exjade or Jadenu and that prescription drug was discontinued due to lack of efficacy, diminished effect, or adverse event.
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist) or has consulted with a specialist.
• 4. The patient will NOT be using the requested agent in combination with another iron chelating agent targeted in this program.
• 5. The patient does NOT have any FDA labeled contraindications to the requested agent.

Reauthorization criteria

• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process.
• 2. The patient has had clinical benefit with the requested agent.
• 3. The patient has an absolute neutrophil count (ANC) ≥ 1.5 × 10^9/L.
• 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist) or has consulted with a specialist.
• 5. The patient will NOT use the requested agent in combination with another iron chelating agent targeted in this program.
• 6. The patient does NOT have FDA labeled contraindications to the requested agent.

Approval duration

12 months