Exjade (deferasirox tablets for suspension) — Cigna

Initial criteria

• Prescriber is a hematologist OR therapy is prescribed in consultation with a hematologist.
• For transfusion-related iron overload: patient is receiving blood transfusions at regular intervals for a chronic condition (e.g., thalassemia syndromes, myelodysplastic syndrome, chronic anemia, or sickle cell disease) AND prior to starting chelating therapy, serum ferritin level > 1,000 mcg/L [documentation required].
• For non-transfusion-dependent thalassemia syndromes: prior to starting chelating therapy, serum ferritin level > 300 mcg/L [documentation required].

Reauthorization criteria

• Patient is currently receiving deferasirox therapy AND is benefiting from therapy according to the prescriber (e.g., reduction in serum ferritin levels, stable disease, or reduced organ iron load).

Approval duration

1 year