Ferriprox (deferiprone) — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following: 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 other FDA approved or compendia-supported indication for requested agent and route
• Absolute neutrophil count (ANC) ≥ 1.5 × 10^9/L AND
• If FDA approved indication, ONE of the following: (A) age within FDA labeling for the indication OR (B) support for using agent for patient’s age for the indication AND
• If request for brand agent, ONE of the following:
• A. BOTH of: (1) ONE of: stage 4 advanced metastatic cancer and requested agent used to treat cancer OR associated condition [chart notes required]; AND (2) use consistent with best practices, evidence-based literature, FDA approved OR
• B. Patient currently treated and stable on requested agent [chart notes required]