CurrentNeighborhood Health Plan of Rhode IslandPolicy 1621-A

Deferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Coverage criteria for deferiprone (Ferriprox) for treatment of transfusional iron overload and hereditary hemochromatosis, including prior authorization documentation and prescriber specialty requirements for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDeferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Policy CodePolicy 1621-A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with pretreatment serum ferritin (and prescriber specialty or hematology consult) for 12-month approval when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period

>=1000pretreatment ferritin

>=500continuation ferritin min

<=99 mg/kgmax daily dose

Hematologistprescriber

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)

Initial therapy: Transfusional iron overload

Authorization of 12 months may be granted for treatment of transfusional iron overload when ALL of the following are met:

Transfusional iron overload - initial criteria: 1) Transfusional iron overload is due to thalassemia syndromes OR sickle cell disease or other anemias; 2) Member does not have transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia; 3) Pretreatment serum ferritin level is greater than 1000 micrograms per liter (mcg/L); 4) Dose will not exceed 99 mg/kg per day.pretreatment ferritin >1000 mcg/L; dose <=99 mg/kg/day

Authorization duration = 12 months

Continuation therapy: Transfusional iron overload

Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for transfusional iron overload when BOTH of the following are met:

Continuation criteria - transfusional iron overload: 1) Member is experiencing benefit from therapy as evidenced by a decrease in serum ferritin levels compared to pretreatment baseline; 2) Serum ferritin level is not below 500 micrograms per liter (mcg/L).serum ferritin >=500 mcg/L

Authorization duration = 12 months

Initial therapy: Hereditary hemochromatosis

Authorization of 12 months may be granted for treatment of hereditary hemochromatosis when the following is met:

Hereditary hemochromatosis criteria: Phlebotomy is not an option (e.g., poor venous access, poor candidate due to underlying medical disorders) OR the member had an unsatisfactory response to phlebotomy.N/A

Authorization duration = 12 months

Continuation therapy: Hereditary hemochromatosis

Authorization of 12 months may be granted for continued treatment in hereditary hemochromatosis when the following is met:

Continuation criteria - hereditary hemochromatosis: Member is experiencing benefit from therapy as evidenced by a decrease in serum ferritin levels compared to pretreatment baseline.N/A

Authorization duration = 12 months

Use of deferiprone for transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia is not established. Such uses are excluded from coverage.

All other indications not specifically listed in this policy are considered experimental/investigational and are not medically necessary.

Indications other than those listed in the coverage criteria (and hereditary hemochromatosis when phlebotomy is not possible as noted) are considered experimental/investigational and not medically necessary.

Laboratory & Dosing Parameters

Serum ferritin (pretreatment and continuation)

Pretreatment serum ferritinGreater than 1000 mcg/L (pretreatment threshold for initial therapy)

Continuation serum ferritinSerum ferritin level not below 500 mcg/L (requirement for reauthorization)

Documentation requirementInitial prior authorization must include a pretreatment serum ferritin; continuation requests must include current serum ferritin level.

Maximum dose

Maximum daily dose limitDose will not exceed 99 mg/kg per day

ApplicabilityApplies to initial therapy for transfusional iron overload as a condition of authorization

Authorization duration impactDose limit is part of criteria for 12‑month authorization

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests. Authorization of up to 12 months may be granted when the applicable clinical criteria for the indication are met.

Prior authorization duration: up to 12 months when criteria are met

Documentation Required

Prescriber Specialty

This medication must be prescribed by or in consultation with a hematologist. Documentation of the prescriber specialty or evidence of a hematology consult should be provided with the request.

Prescriber requirement: hematologist or consult with hematologist
Provide documentation of prescriber specialty or consult

Denial Risk

Excluded Diagnoses

Requests for treatment of transfusional iron overload where the iron overload is due to myelodysplastic syndrome or Diamond Blackfan anemia are excluded; safety and effectiveness have not been established for these diagnoses.

Excluded diagnoses: myelodysplastic syndrome
Excluded diagnoses: Diamond Blackfan anemia

Key Definitions

Transfusional iron overload

DefinitionTransfusional iron overload: accumulation of iron due to repeated blood transfusions occurring in conditions such as thalassemia syndromes, sickle cell disease, and other anemias.

Common underlying conditionsThalassemia syndromes

Common underlying conditionsSickle cell disease and other anemias

ExclusionsNot established for transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia (use is excluded).

Hereditary hemochromatosis (phlebotomy alternative)

DefinitionHereditary hemochromatosis: use of deferiprone when standard phlebotomy is not an option or produced an unsatisfactory response.

Acceptable reasons to defer phlebotomyPoor venous access or member is a poor candidate due to underlying medical disorders

AuthorizationAuthorization of 12 months may be granted when phlebotomy is not an option or was unsuccessful

OpenPayer

Deferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Coverage Criteria for Deferiprone (Ferriprox)

Laboratory & Dosing Parameters

Prior Authorization, Documentation, and Prescriber Requirements

Key Definitions

Background