Ferriprox — CareFirst (Caremark)
Transfusional iron overload due to sickle cell disease or other anemias
Initial criteria
- Transfusional iron overload is due to thalassemia syndromes OR sickle cell disease or other anemias
- Member does not have transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia
- Pretreatment serum ferritin level is consistently greater than 1000 mcg/L
- Dose will not exceed 99 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