deferasirox — CareFirst (Caremark)
Chronic iron overload due to blood transfusions (transfusional hemosiderosis)
Initial criteria
- Pretreatment serum ferritin level is consistently greater than 1000 mcg/L
- Dose of deferasirox tablet for suspension/Exjade will not exceed 40 mg/kg per day
- Dose of deferasirox/Jadenu will not exceed 28 mg/kg per day
Reauthorization criteria
- Member is experiencing benefit from therapy as evidenced by a decrease in serum ferritin levels as compared to pretreatment baseline
- Serum ferritin level is not consistently below 500 mcg/L
Approval duration
6 months