Medical Policy

Effective Date:01/01/2012 Title:Ferriprox (Deferiprone)
Revision Date:10/01/2015 Document:BI360:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1)    Ferriprox (Deferiprone) requires prior authorization.

2)    Ferriprox (Deferiprone) is an oral medication covered for the treatment of patients with transfusional iron overload due to thalassemia syndromes when current chelation therapy is inadequate.

3)    Ferriprox is not covered for other uses.

4)    Ferriprox is covered under the pharmacy benefit.

Medical Statement

Ferripriox (Deferiprone) is considered medically necessary for patients meeting the following criteria:

1)    Diagnosis of transfusional iron overload due to thalassemia syndrome(D56.0 – D56.9);  AND

2)    Absolute Neutrophil Count (ANC) is greater than 1.5 x 109/L; AND

3)    Failure of prior chelation therapy with Desferal (deferoxamine) or Exjade (deferasirox) as evidenced by serum ferritin levels of > 2,500 mcg/L;  OR

4)    Documented intolerance or contraindication to parenteral deferoxamine (Desferal) or Exjade (deferasirox).

 

Authorization for continued use shall be reviewed at least annually to confirm the following:

·         Patient has experienced >20% decline in serum ferritin levels from baseline AND

·         ANC > 0.5 x 109/L

Limits
Intentially left empty
Reference

1)    Ferriprox Product Information.  Apotex, Inc.  October 2011

2)    Clinical Pharmacology.  Ferriprox.  Accessed online March 2012.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.