deferasirox — CareFirst (Caremark)
Chronic iron overload in patients with non-transfusion-dependent thalassemia (NTDT) syndromes
Initial criteria
- Member meets any of the following: Pretreatment serum ferritin level ≥ 800 mcg/L; OR Pretreatment liver iron concentration (LIC) ≥ 5 mg Fe/g dw; OR Pretreatment serum ferritin level > 300 mcg/L to < 800 mcg/L with clinical or laboratory measures indicative of iron overload (e.g., liver disease, renal disease)
- Dose of deferasirox tablet for suspension/Exjade will not exceed 20 mg/kg per day
- Dose of deferasirox/Jadenu will not exceed 14 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 300 mcg/L
Approval duration
6 months