Exjade (deferasirox) — Blue Cross Blue Shield of Texas

chronic iron overload due to a non-transfusion dependent thalassemia syndrome

Preferred products

ONE of the following: (A) chronic iron overload due to blood transfusions with current serum ferritin >500 mcg/L if treated within past 90 days, OR (B) chronic iron overload due to a non-transfusion dependent thalassemia syndrome AND (1) baseline liver iron concentration ≥5 mg FE/g dry weight OR serum ferritin >300 mcg/L OR MRI confirmation of iron deposition AND (2) if treated within past 90 days, LIC >3 mg FE/g dry weight, OR (C) another FDA approved indication, OR (D) another compendia-supported indication
If FDA approved indication, patient's age is within FDA labeling OR supported for use with that age
If brand agent with generic equivalent (Exjade/Jadenu), ONE of: (A) metastatic cancer use as defined, (B) currently stable on agent, (C) tried and inadequate response to generic, (D) discontinued generic for lack of efficacy or adverse event, (E) intolerance/hypersensitivity to generic, (F) FDA labeled contraindication to generic not expected with brand, (G) generic expected ineffective or detrimental as defined, (H) generic not in patient best interest, (I) tried another agent in same class with failure, (J) support for brand over generic
Patient does NOT have severe hepatic impairment (Child-Pugh-Turcotte C)
Prescriber is a specialist or has consulted one
Patient will NOT use in combination with another iron chelating agent targeted in this program
Patient does NOT have any FDA labeled contraindications to requested agent

Previously approved for requested agent through plan's PA
ONE of: (A) diagnosis of chronic iron overload due to blood transfusions with decrease in serum ferritin from baseline AND current ferritin >500 mcg/L, OR (B) non-transfusional iron overload due to thalassemia with current ferritin >300 mcg/L, OR (C) other diagnosis with clinical benefit
Patient does NOT have severe hepatic impairment (Child-Pugh-Turcotte C)
Prescriber is a specialist or consulted specialist
Patient will NOT use in combination with another iron chelating agent targeted in this program
Patient does NOT have any FDA labeled contraindications

12 months