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Jadenu (deferasirox) — Blue Cross Blue Shield of Illinois

chronic iron overload due to blood transfusions

Preferred products

  • Generic deferasirox

Initial criteria

  • If treated with a deferasirox agent within the past 90 days, current (within 30 days) serum ferritin > 500 mcg/L OR
  • Diagnosis of chronic iron overload due to a non-transfusion dependent thalassemia syndrome AND BOTH: (1) ONE of: baseline LIC ≥ 5 mg FE/g dry weight OR serum ferritin > 300 mcg/L OR MRI confirmation of iron deposition; AND (2) If treated with a deferasirox agent within 90 days, LIC > 3 mg FE/g dry weight OR
  • Other FDA approved indication or compendia supported indication for requested agent and route, AND if FDA approved indication, patient’s age is within FDA labeling or supported for the use
  • If brand requested and a generic equivalent exists (Exjade/Jadenu correspond to generic deferasirox), ONE of A–J applies (stage IV metastatic cancer use, stable use, failed generic equivalent, intolerance/hypersensitivity, contraindication, expected ineffective or harmful response, medical necessity support, or supported use of brand over generic)
  • Patient does NOT have severe hepatic impairment (Child-Pugh-Turcotte C)
  • Prescriber is a specialist (e.g., hematologist) or has consulted with a specialist
  • Patient will NOT use the requested agent in combination with another iron chelating agent targeted in this program
  • Patient does NOT have FDA labeled contraindications

Reauthorization criteria

  • Previously approved through plan’s prior authorization process
  • Diagnosis of chronic iron overload due to transfusions AND BOTH: decreased serum ferritin from baseline AND current serum ferritin > 500 mcg/L OR
  • Diagnosis of non-transfusional iron overload due to thalassemia syndromes AND current serum ferritin > 300 mcg/L OR
  • Other diagnosis with clinical benefit from requested agent
  • Patient does NOT have severe hepatic impairment (Child-Pugh-Turcotte C)
  • Prescriber is a specialist or has consulted a specialist
  • Patient will NOT use in combination with another targeted iron chelating agent
  • Patient does NOT have FDA labeled contraindications

Approval duration

12 months