Ferriprox (deferiprone) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Diagnosis of transfusional iron overload with thalassemia syndromes OR
• Diagnosis of 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
• Has another FDA approved indication or compendia supported indication for requested agent and route of administration AND
• Absolute neutrophil count (ANC) ≥1.5 x 10^9/L AND
• If patient has FDA approved indication: ONE of the following:
• - Patient’s age within FDA labeling for requested indication for requested agent OR there is support for use for patient’s age for requested indication AND
• If request is for brand agent, ONE of the following:
• - Both of: (1) Patient with stage four advanced metastatic cancer where requested agent used to treat cancer or associated condition [chart notes required]; AND (2) Use consistent with best practices, evidence-based literature, and FDA approval OR
• - Patient currently stable on requested agent [chart notes required] OR
• - Tried and had inadequate response to generic equivalent [chart notes required] OR
• - Generic equivalent discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• - Patient intolerance or hypersensitivity to generic equivalent not expected with brand [chart notes required] OR
• - FDA labeled contraindication to generic equivalent not expected with brand [chart notes required] OR
• - Generic equivalent expected ineffective, cause adherence barrier, worsen comorbid condition, cause harm, or impact daily functional ability [chart notes required] OR
• - Generic equivalent not in best interest of patient based on medical necessity [chart notes required] OR
• - Patient tried another drug in same pharmacologic class discontinued due to lack of efficacy or adverse event [chart notes required] OR
• - There is support for the use of the requested brand agent over the generic equivalent