generic deferasirox — Medica

Initial criteria

• For transfusion-related iron overload: ALL of the following (i, ii, and iii) must be met: i) Patient is receiving blood transfusions at regular intervals for a chronic condition (e.g., thalassemia syndromes, myelodysplastic syndrome, chronic anemia, sickle cell disease); AND ii) Prior to starting chelating therapy, serum ferritin level was > 1,000 mcg/L [documentation required]; AND iii) The medication is prescribed by or in consultation with a hematologist.
• For non-transfusion-dependent thalassemia syndromes: BOTH of the following (i and ii) must be met: i) Prior to starting chelating therapy, serum ferritin level was > 300 mcg/L [documentation required]; AND ii) The medication is prescribed by or in consultation with a hematologist.

Reauthorization criteria

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

Approval duration

1 year