CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Deferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Covers clinical prior authorization criteria, documentation, and continuation requirements for deferiprone (Ferriprox) oral solution and tablets used to treat transfusional iron overload and select compendial use (hereditary hemochromatosis) 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 N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with pretreatment serum ferritin for initial requests and current ferritin for continuation; prior auth may be granted for 6 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthstypical authorization duration

>1000 mcg/Linitial ferritin threshold

not <500 mcg/Lcontinuation ferritin limit

99 mg/kg/daydose maximum

Coverage Criteria for Deferiprone (Ferriprox)

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Initial Therapy — Transfusional Iron Overload

Covered when ALL of the following are met:

Initial Transfusional Iron Overload Criteria: 1) Transfusional iron overload due to thalassemia syndromes OR sickle cell disease/other anemias; 2) Not due to myelodysplastic syndrome or Diamond Blackfan anemia; 3) Pretreatment serum ferritin level consistently > 1000 mcg/L; 4) Planned dose will not exceed 99 mg/kg per day.

Authorization of 6 months may be granted when met.

Initial Therapy — Hereditary Hemochromatosis

Covered when ALL of the following are met:

Hereditary Hemochromatosis Initial Criteria: 1) Phlebotomy is not an option (e.g., medical contraindication) OR member had an unsatisfactory response to phlebotomy.

Authorization of 6 months may be granted.

Continuation Therapy — Transfusional Iron Overload

Covered when ALL of the following are met:

Continuation Transfusional Iron Overload Criteria: 1) Member is experiencing benefit from therapy as evidenced by a decrease in serum ferritin compared to pretreatment baseline; 2) Serum ferritin level is not consistently below 500 mcg/L.

Authorization of 6 months may be granted for continued treatment.

Continuation Therapy — Hereditary Hemochromatosis

Covered when the following is met:

Continuation Hereditary Hemochromatosis Criteria: Member is experiencing benefit from therapy as evidenced by a decrease in serum ferritin compared to pretreatment baseline.

Authorization of 6 months may be granted for continued treatment.

This policy excludes treatment of transfusional iron overload when it is due to myelodysplastic syndrome or Diamond Blackfan anemia. In addition, all other indications not specifically listed in the coverage criteria are considered experimental/investigational and not medically necessary and may be denied.

Use of deferiprone for any indication other than the FDA‑approved transfusional iron overload indications and the specified compendial use (hereditary hemochromatosis when phlebotomy is not an option) is considered experimental/investigational and not medically necessary.

Coding, Dosing, and Thresholds

References and package inserts (no billing codes provided)mixed

No codes listed

inv-08: Serum ferritin thresholds — Initial and Continuation values

Initial thresholdPretreatment serum ferritin level consistently >1000 mcg/L

Continuation thresholdSerum ferritin not consistently <500 mcg/L (i.e., level is not consistently below 500 mcg/L)

ContextThresholds apply to transfusional iron overload treatment decisions for deferiprone (Ferriprox)

inv-09: Maximum daily dose — dosing limit

Maximum daily doseDose will not exceed 99 mg/kg per day

ApplicabilityDose limit applies to initial therapy criteria for transfusional iron overload

DrugDeferiprone (Ferriprox)

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for deferiprone (Ferriprox) for transfusional iron overload and hereditary hemochromatosis. Authorizations are typically granted for up to 6 months when criteria are met.

Authorization duration: 6 months
Applies to both initial and continuation requests when criteria are satisfied

Documentation Required

Phlebotomy Prerequisite for Hereditary Hemochromatosis

For hereditary hemochromatosis, phlebotomy must be attempted or documented as not an option before authorization of deferiprone will be considered. Authorization may be allowed when phlebotomy is not an option (for example, patient is a poor candidate due to underlying medical disorders) or when the member had an unsatisfactory response to phlebotomy.

Phlebotomy prerequisite applies to initial therapy for hereditary hemochromatosis
If phlebotomy is not possible, documentation of the medical reason or prior unsatisfactory response must be provided

Documentation Required

Required Laboratory Documentation (Ferritin)

Required laboratory documentation must be submitted with requests: pretreatment and ongoing serum ferritin levels. For initial requests for transfusional iron overload, provide a pretreatment serum ferritin level consistently > 1000 mcg/L. For continuation requests, provide current serum ferritin showing benefit from therapy (a decrease from pretreatment baseline) and serum ferritin not consistently below 500 mcg/L. For hereditary hemochromatosis continuation requests, provide evidence of benefit demonstrated by a decrease in serum ferritin compared to pretreatment baseline.

Transfusional iron overload — initial: pretreatment serum ferritin > 1000 mcg/L
Transfusional iron overload — continuation: current serum ferritin with documented decrease from baseline and not consistently < 500 mcg/L
Hereditary hemochromatosis — initial: documentation that phlebotomy is not an option or was ineffective; pretreatment ferritin as applicable
Hereditary hemochromatosis — continuation: current ferritin showing decrease from pretreatment baseline

Denial Risk

Experimental / Not Medically Necessary Triggers

Requests for indications not listed as covered (including treatment of transfusional iron overload due to myelodysplastic syndrome or Diamond Blackfan anemia, and any other unlisted indications) are considered experimental/investigational and not medically necessary and will be denied.

Transfusional iron overload due to myelodysplastic syndrome — not covered
Diamond Blackfan anemia — not covered
All other unlisted indications — experimental/not medically necessary

Key Definitions

inv-15: Transfusional iron overload — definition and example conditions

DefinitionTransfusional iron overload: excess body iron from repeated blood transfusions in conditions such as thalassemia syndromes, sickle cell disease, or other anemias

Example conditionsThalassemia syndromes; sickle cell disease; other anemias requiring chronic transfusions

Exclusion exampleNot due to myelodysplastic syndrome or Diamond Blackfan anemia (these causes are excluded from coverage)

inv-16: Hereditary hemochromatosis (compendial use) — definition and phlebotomy exception

DefinitionHereditary hemochromatosis: compendial (non‑FDA) indication for deferiprone when standard therapy is unsuitable

Phlebotomy exceptionAuthorization allowed when phlebotomy is not an option (e.g., medical contraindication) or when phlebotomy was unsuccessful

ScopeUse is limited to cases meeting compendial criteria; standard transfusional iron overload criteria differ (see transfusional definitions)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDeferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with pretreatment serum ferritin for initial requests and current ferritin for continuation; prior auth may be granted for 6 months when criteria are met.

SourceLink

On This Page

OpenPayer

Deferiprone (Ferriprox) — Coverage Criteria for Iron Overload

Coverage Criteria for Deferiprone (Ferriprox)

Coding, Dosing, and Thresholds

Prior Authorization, Documentation, and Provider Requirements

Background and Drug Information

Key Definitions