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Exjade (deferasirox) — Highmark

Chronic iron overload in non–transfusion-dependent thalassemia (NTDT) syndromes

Preferred products

  • generic deferasirox tablets

Initial criteria

  • age ≥ 10 years
  • diagnosis of chronic iron overload due to non–transfusion-dependent thalassemia (ICD-10: D56.0, D56.1, D56.5)
  • LIC ≥ 5 mg Fe/g dw
  • serum ferritin > 300 mcg/L
  • 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)