Skip to content
The Policy VaultThe Policy Vault

Exjade (deferasirox) — Highmark

Chronic iron overload due to blood transfusions

Preferred products

  • generic deferasirox tablets

Initial criteria

  • age ≥ 2 years
  • diagnosis of chronic iron overload due to blood transfusions (ICD-10: E83.111)
  • transfusion history of ≥ 100 mL/kg of packed red blood cells (at least 20 units for a 40 kg person or more in individuals weighing more than 40 kg)
  • serum ferritin consistently > 1,000 mcg/L OR liver iron concentration (LIC) ≥ 7 mg Fe/g dw
  • If request is for brand Jadenu tablets, member has experienced therapeutic failure or intolerance to generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)
  • If request is for brand Exjade or Jadenu Sprinkles, member has experienced therapeutic failure or intolerance to plan-preferred generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)

Reauthorization criteria

  • prescriber attests member has experienced positive clinical response to therapy
  • member continues to require regular blood transfusions
  • serum ferritin level ≥ 500 mcg/L OR LIC ≥ 3 mg Fe/g dw
  • If request is for brand Jadenu tablets, member has experienced therapeutic failure or intolerance to generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)
  • If request is for brand Exjade or Jadenu Sprinkles, member has experienced therapeutic failure or intolerance to plan-preferred generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)