Ferriprox oral solution — Medica
patients who meet the standard Chelating Agents – Iron Chelators (Oral) Prior Authorization Policy criteria
Preferred products
- generic deferasirox tablets
- generic deferasirox tablets for suspension
- generic deferasirox granules
- generic deferiprone tablets
Initial criteria
- Patient meets the standard Chelating Agents – Iron Chelators (Oral) Prior Authorization Policy criteria; AND
- Patient meets ONE of the following (i, ii, or iii):
- i. Patient has tried ONE of generic deferasirox tablets, generic deferasirox tablets for suspension, generic deferasirox granules, or generic deferiprone tablets; OR
- ii. The dose prescribed cannot be attained with deferiprone tablets; OR
- iii. Patient cannot swallow or has difficulty swallowing deferiprone tablets.
Approval duration
1 year