Ferriprox (deferiprone) — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of transfusional iron overload with thalassemia syndromes OR transfusional iron overload with sickle cell disease or other anemias AND patient does NOT have myelodysplastic syndrome AND does NOT have Diamond Blackfan anemia OR another FDA approved indication OR other compendia-supported indication
• Absolute neutrophil count (ANC) ≥ 1.5 × 10^9/L
• If FDA approved indication, patient's age is within FDA labeling for the indication OR there is support for using requested agent for patient's age for the indication
• If request is for a brand agent, then ONE of: (A) advanced metastatic cancer criteria met; OR (B) patient stable on agent