ModifiedHealth NetPolicy CP PHAR.147

Deferiprone (Ferriprox) — coverage for transfusional iron overload

Defines medical necessity, prior authorization and continuation criteria for deferiprone (Ferriprox and generic deferiprone) for transfusional iron overload in pediatric and adult members across Health Net lines of business.

Policy Summary

PayerHealth Net

PolicyDeferiprone (Ferriprox) — coverage for transfusional iron overload

Policy CodePolicy CP PHAR.147

Change TypeStep therapy bypassthreshold revisiongeneric redirection

Effective Date11.01.15

Next Review Date

Key ActionSubmit prior authorization with diagnosis, transfusion history, serum ferritin, age/formulation, prior chelator history, and planned dose (≤99 mg/kg/day).

SourceLink

POLICY UPDATE CHANGES

Added step therapy bypass for Illinois HIM per IL HB 5395.

Revised concurrent iron chelator bypass threshold from cardiac T2* 20 ms to mT2* 10 ms per TIF guidelines for chronic iron overload.

Added requirement that therapy does not include concurrent use of other iron chelators unless excess cardiac iron is present.

Policy is medically necessary for all deferiprone products, not only Ferriprox; generic deferiprone redirection for ages ≥8 years was added.

Policy clarified that deferiprone is medically necessary for all deferiprone products, not only Ferriprox.

Added generic deferiprone redirection for ages Z8 years.

Added step therapy bypass for IL HIM per IL HB 5395.

Revised concurrent iron chelator bypass threshold from cardiac T2* 20 ms to mT2* 10 ms for chronic iron overload per TIF guidelines.

Added HIM line of business.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Deferiprone (Ferriprox and generics)

inv-01: Initial Therapy

Covered when ALL of the following initial criteria are met:

Initial Approval for Transfusional Iron Overload: 1) Diagnosis of transfusional iron overload due to thalassemia syndromes, sickle cell disease, or other anemia; 2) Age/formulation: tablets >= 8 years OR oral solution >= 3 years; 3) Serum ferritin > 1,000 mcg/L; 4) Transfusion history >= 100 mL/kg packed red blood cells (example: ~20 units for a 40 kg person); 5) Trial and failure of deferoxamine and deferasirox unless contraindicated or clinically significant adverse effects are experienced (step therapy requirements do not apply for Illinois HIM requests per IL HB 5395 effective 1/1/2026); 6) Therapy does not include concurrent use of other iron chelators unless member has excess cardiac iron as evidenced by cardiac T2* (mT2*) <= 10 ms or iron-induced cardiomyopathy; 7) Dose does not exceed 99 mg/kg/day.

If age >= 8 years, member must use generic deferiprone tablet unless contraindicated or clinically significant adverse effects occur.

inv-02: Continuation Therapy

Covered for continued therapy when ALL of the following are met:

Continuation Therapy: 1) Member is currently receiving the medication via the health plan benefit or has previously met initial approval criteria; 2) Member is responding positively to therapy as evidenced by a decrease in serum ferritin compared to pretreatment baseline; 3) Recent documentation (within the past 30 days) shows serum ferritin >= 500 mcg/L; 4) If age >= 8 years, member must use generic deferiprone tablet unless contraindicated or clinically significant adverse effects are experienced (Illinois HIM step therapy exception applies as noted); 5) Therapy does not include concurrent use of other iron chelators unless member has excess cardiac iron as evidenced by cardiac T2* (mT2*) < = 10 ms or iron-induced cardiomyopathy; 6) If request is for a dose increase, the new dose must not exceed 99 mg/kg/day.

Approval duration: 12 months.

inv-03: General coverage

Covered when meeting Health Plan medical necessity criteria and applicable state-specific provisions; edits below reflect recent clarifications and thresholds.

General coverage stance: Deferiprone is medically necessary for all deferiprone products (not only Ferriprox).

Policy includes redirection to generic deferiprone for ages >= 8 years as stated in the criteria and applies HIM line of business considerations where noted.

inv-04: Step therapy / bypass

Step therapy and bypass criteria (state-specific adjustments):

Step therapy bypass for Illinois HIM: Step therapy bypass added for Illinois HIM per IL HB 5395 (effective 1/1/2026).

Applies to HIM line of business in Illinois; when applicable, prior failure of deferoxamine and deferasirox is not required.

Concurrent iron chelator bypass for chronic iron overload: Bypass to allow concurrent use of other iron chelators when excess cardiac iron is present.cardiac T2* (mT2*) <= 10 ms

Concurrent chelators allowed only if cardiac T2* (mT2*) <= 10 ms (revised from 20 ms per TIF guidelines) or in presence of iron-induced cardiomyopathy.

The policy lists specific exclusions under the coverage criteria. Parkinson's disease is identified as an explicit exclusion. For other non‑FDA approved indications not addressed in this policy, coverage is not authorized unless sufficient documentation of efficacy and safety is provided in accordance with the referenced off‑label use policies.

In the excerpt reviewed there are no additional explicit exclusions listed beyond those previously recorded. The policy text clarifies applicability across deferiprone products and includes state‑specific operational notes, but does not add new exclusionary indications in this section.

Deferiprone is covered for the FDA‑approved indication of transfusional iron overload in patients with thalassemia syndromes, sickle cell disease, or other anemias when the policy criteria are met. Age and formulation limits are applied (tablets: ≥ 8 years; oral solution: ≥ 3 years). The policy also requires meeting objective thresholds and prior‑therapy requirements (e.g., serum ferritin and prior failure of other chelators) and specifies that therapy should not include concurrent iron chelators unless there is evidence of excess cardiac iron (cardiac T2* criteria recently revised).

The excerpt does not add any standalone 'not medically necessary' declarations beyond the documented limitation of use in the prescribing information. The policy does note that use for transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia is not supported by safety/effectiveness data and therefore is not authorized under the coverage criteria.

Key Clinical Thresholds and Dosing

inv-09: Serum ferritin — initiation and continuation thresholds

Initiation ferritin thresholdSerum ferritin > 1,000 mcg/L for initial approval

Continuation ferritin thresholdSerum ferritin ≥ 500 mcg/L documented within the past 30 days for continued therapy

Required documentation timingFerritin result must be current within 30 days of request

inv-10: Transfusion history — documented transfusion volume requirement

Transfusion volume requirementTransfusion history ≥ 100 mL/kg of packed red blood cells (e.g., ~20 units for a 40 kg person)

ContextRequired as part of initial approval criteria for transfusional iron overload

Prior Authorization, Documentation, and Operational Notes

Prior Authorization

Prior Authorization Required and Documentation

Prior authorization is required. Provider must submit documentation (office chart notes, lab results, or other clinical information) supporting diagnosis and that member meets all approval criteria including transfusion history, serum ferritin, age/formulation, prior chelator failure or contraindication, and dosing limits. Deferiprone is considered medically necessary for all deferiprone products (not limited to Ferriprox); authorization should reflect the specific product requested.

Required documentation: office chart notes, laboratory results (including serum ferritin and cardiac T2* when applicable), transfusion records, and prior therapy history.
Approval requires demonstration of transfusional iron overload diagnosis and transfusion history (e.g., ≥100 mL/kg packed RBCs).
Dose limit: does not exceed 99 mg/kg per day.
Authorization must specify the exact deferiprone product requested.

Step Therapy

Step Therapy Requirements and State Exceptions

Initial Approval Criteria

inv-25: Initial therapy

Covered when ALL of the following initial criteria are met:

Initial therapy: 1) Diagnosis of transfusional iron overload; 2) Age and formulation criteria met (tablets >= 8 years, oral solution >= 3 years); 3) Serum ferritin > 1,000 mcg/L; 4) Transfusion history >= 100 mL/kg packed RBCs; 5) Prior failure or intolerance to deferoxamine and deferasirox unless contraindicated or IL HIM bypass applies; 6) No concurrent iron chelators unless cardiac T2* <= 10 ms or iron-induced cardiomyopathy; 7) Dose <= 99 mg/kg/day.

Generic deferiprone must be used for ages >=8 years unless contraindicated or clinically significant adverse effects are experienced. Authorization should reflect product (brand or generic).

Criteria for Continued Therapy and Monitoring

inv-26: Continuation therapy

Continuation criteria and monitoring

Continuation: 1) Member demonstrates a decrease in serum ferritin from pretreatment baseline and current ferritin >= 500 mcg/L within the past 30 days; 2) Member is currently receiving medication via the benefit or previously met initial criteria; 3) If age >=8 years, adhere to generic deferiprone tablet redirection unless contraindicated or adverse effects; 4) No concurrent iron chelators unless cardiac T2* <= 10 ms or iron-induced cardiomyopathy; 5) If dose increase requested, new dose must not exceed 99 mg/kg/day.

Approval duration for continued therapy: 12 months. Providers should include lab documentation and prior therapy history with prior authorization requests.

inv-11: Approval duration for continued therapy — Approval duration / monitoring cadence (refer to continuation criteria block)

Approval duration for continued therapyApproval duration: 12 months

Monitoring cadenceContinuation requires current ferritin within 30 days and demonstration of decreased ferritin from baseline

Step Therapy Requirements and State Bypasses

Step	Requirement / Details	Coverage status
1	Prior failure of deferoxamine and deferasirox is required before approval of deferiprone, unless both are contraindicated or clinically significant adverse effects occurred.	Prior failure required
	For Illinois HIM requests, step therapy requirements do not apply effective 1/1/2026 per IL HB 5395.	Bypass per IL law

Bypass / Exception	Criteria / Threshold	Coverage status
Illinois HIM step therapy bypass	Step therapy requirements do not apply for Illinois HIM requests per IL HB 5395 (effective 1/1/2026).	Bypass (IL HIM)
Concurrent iron chelator allowance (chronic iron overload)	Concurrent use of other iron chelators is allowed only if there is evidence of excess cardiac iron: cardiac T2* (mT2*) ≤ 10 milliseconds or iron‑induced cardiomyopathy.	Threshold-based bypass

Background — Drug and Indications

Deferiprone is an oral iron chelator indicated for the treatment of transfusional iron overload in adults and pediatric patients with thalassemia syndromes, sickle cell disease, or other anemias. Tablet formulation is approved for patients aged 8 years and older, and the oral solution is approved for patients aged 3 years and older. The prescribing information includes limitations of use: safety and effectiveness have not been established for transfusional iron overload in patients with myelodysplastic syndrome or Diamond Blackfan anemia. The medication carries boxed warnings for agranulocytosis and neutropenia requiring appropriate monitoring.

Definitions and Formulation Age Limits

inv-23: Deferiprone (Ferriprox) — formulation age limits and indication summary

Formulations and minimum agesTablets: approved for ages ≥ 8 years; Oral solution: approved for ages ≥ 3 years

Indication summaryIndicated for treatment of transfusional iron overload in thalassemia syndromes, sickle cell disease, or other anemias

Warnings/contraindicationsContraindicated in hypersensitivity; boxed warnings include agranulocytosis and neutropenia (monitoring required)

Policy note on productsPolicy states deferiprone is medically necessary for all deferiprone products (not only Ferriprox) with generic redirection for ages ≥8 years

inv-24: cardiac T2* — cardiac T2* (mT2*) threshold definition reference

Definition of cardiac T2* threshold

Policy Summary

PayerHealth Net

PolicyDeferiprone (Ferriprox) — coverage for transfusional iron overload

Policy CodePolicy CP PHAR.147

Change TypeStep therapy bypassthreshold revisiongeneric redirection

Effective Date11.01.15

Next Review Date

Key ActionSubmit prior authorization with diagnosis, transfusion history, serum ferritin, age/formulation, prior chelator history, and planned dose (≤99 mg/kg/day).

SourceLink

On This Page

Documentation Required

Cardiac T2* (mT2*) Requirement for Concurrent Chelation

Concurrent use of multiple iron chelators is generally not approved unless member has excess cardiac iron or iron-induced cardiomyopathy. Cardiac T2* (mT2*) values must be documented when claiming excess cardiac iron; concurrent chelator bypass threshold for chronic iron overload is cardiac mT2* ≤ 10 milliseconds.

Document cardiac T2* (mT2*) value to support concurrent chelation (threshold: ≤ 10 ms).
Providers should include imaging or cardiology reports showing mT2* when requesting concurrent chelation.

Denial Risk

Denial Risks and Triggers

Denials will occur if submitted documentation does not demonstrate that the member meets all approval criteria, or if the indication is a non‑FDA‑approved use without appropriate off‑label justification per off‑label policies.

Requests lacking documentation of diagnosis, transfusion history, serum ferritin, age/formulation, prior chelator trials or contraindications, and cardiac mT2* when applicable will be denied.
Off‑label uses require sufficient supporting documentation per applicable off‑label policies.

Note

Operational Notes

Operational notes: indicate IL HIM applicability when relevant; for chronic iron overload, concurrent chelator bypass threshold updated to cardiac mT2* ≤ 10 ms per TIF guidelines; policy applies to all deferiprone products and includes generic redirection for ages ≥8 years.

State-specific: IL HIM — step therapy bypass applies per IL HB 5395 (effective 1/1/2026).
Product applicability: policy covers all deferiprone products (not limited to Ferriprox); authorization should reflect product.
Providers should explicitly document cardiac T2* values and note any state-specific step therapy bypass requests.