Ferriprox (deferiprone) — Blue Cross Blue Shield of Illinois

Initial criteria

• 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 other FDA approved or compendia supported indication
• Absolute neutrophil count (ANC) ≥ 1.5 x 10^9/L
• If FDA approved indication, patient’s age within FDA labeling or supported for the indication
• If brand agent requested, ONE of A–J applies (stage IV metastatic cancer use, stability, trial and failure or intolerance of generic equivalent or class alternative, medical necessity justification, or supported use of brand)