Ferriprox (deferiprone) — Highmark
Transfusional iron overload due to thalassemia syndromes, sickle cell disease, or other anemias
Preferred products
- generic deferasirox tablets
Initial criteria
- age ≥ 8 years (for tablets) OR age ≥ 3 years (for oral solution)
- diagnosis of transfusional iron overload due to thalassemia syndromes, sickle cell disease, or other anemias (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 LIC ≥ 7 mg Fe/g dw
- If request is for brand Ferriprox, member has experienced therapeutic failure or intolerance to plan-preferred generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)
- If request is for brand Ferriprox, member has experienced therapeutic failure or intolerance to generic deferiprone tablets
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 Ferriprox, member has experienced therapeutic failure or intolerance to plan-preferred generic deferasirox tablets (failure/intolerance to generic deferasirox granules not accepted)
- If request is for brand Ferriprox, member has experienced therapeutic failure or intolerance to generic deferiprone tablets