Exjade — 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
12 months