Pharmacy Prior Authorization Criteria

Ferriprox (deferiprone)

Indications for Prior Authorization

Ferriprox (deferiprone) Tablets

• For diagnosis of Iron Overload
  Indicated for the treatment of transfusional iron overload in adult and pediatric patients 8 years of age and older with thalassemia syndromes, sickle cell disease or other anemias.

  Limitations of Use: Safety and effectiveness have not been established for the treatment of transfusional iron overload in patients with myelodysplastic syndrome or in patients with Diamond Blackfan anemia.

Ferriprox (deferiprone) Oral Solution

• For diagnosis of Iron Overload
  Indicated for the treatment of transfusional iron overload in adult and pediatric patients 3 years of age and older with thalassemia syndromes, sickle cell disease or other anemias.

  Limitations of Use: Safety and effectiveness have not been established for the treatment of transfusional iron overload in patients with myelodysplastic syndrome or in patients with Diamond Blackfan anemia.

Criteria

Ferriprox oral solution, Generic deferiprone tablet

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of transfusional iron overload due to one of the following: [1]
• Thalassemia syndromes
• Sickle cell disease
• Other transfusion-dependent anemias
AND
• One of the following:
• For Ferriprox oral solution, patient is 3 years of age or older
OR
• For generic deferiprone tablet, patient is 8 years of age or older
AND
• Trial (of a minimum 30 day supply) and failure (defined by a serum ferritin > 2,500 mcg/L), contraindication or intolerance to one of the following chelation therapy [A]:
• Generic deferoxamine
• Generic deferasirox
AND
• Absolute Neutrophil Count (ANC) greater than 1.5 x 10^9/L

Brand Ferriprox tablet

*Product may require prior authorization

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of transfusional iron overload due to one of the following: [1]
• Thalassemia syndromes
• Sickle cell disease
• Other transfusion-dependent anemias
AND
• Patient is 8 years of age or older
AND
• Trial (of a minimum 30 day supply) and failure (defined by a serum ferritin > 2,500 mcg/L), contraindication or intolerance to one of the following chelation therapy [A]:
• Generic deferoxamine
• Generic deferasirox
AND
• Absolute Neutrophil Count (ANC) greater than 1.5 x 10^9/L
AND
• Trial and failure, or intolerance to generic deferiprone tablets*

Brand Ferriprox tablet, Ferriprox oral solution, Generic deferiprone tablet

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient has experienced greater than or equal to 20% decline in serum ferritin levels from baseline
AND
• Absolute Neutrophil Count (ANC) greater than 1.5 x 10^9/L
AND
• For Brand Ferriprox tablets, trial and failure, or intolerance to generic deferiprone tablets

P & T Revisions

2024-03-27, 2023-03-08, 2022-04-21, 2021-06-18, 2021-05-20, 2021-03-03, 2020-10-26, 2020-08-27, 2020-03-05, 2019-09-20

References

1. Ferriprox tablets prescribing information. Apotex Inc., Toronto, Canada. July 2023.
2. Ferriprox solution prescribing information. Apotex Inc., Toronto, Canada. November 2021.
3. Deferiprone prescribing information. Taro Pharmaceutical Industries Ltd. Haifa Bay, Israel. January 2024.

---

End Notes

1. Failure to prior chelation therapy is defined as serum ferritin > 2,500 mcg/L. [1]

---

Revision History

• 2024-03-27: 2024 UM Annual Review. Added t/f of generic deferiprone to reauth criteria for Brand Ferriprox tablets. Combined t/f or contraindication/intolerance of one prior chelation therapy into one criteria with no changes to clinical intent. Background updates.
• 2023-03-08: 2023 UM Annual Review. Added age criteria to align with package insert. Removed SP formulary and kept only standard formulary attached to guideline. Updated references
• 2022-04-21: Update to add generic deferiprone tablet as an embedded step to the target drug brand Ferriprox, updated background information
• 2021-06-18: Updated program to reflect updated indication. Formatting updates with no change to clinical intent.
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-03-03: Annual Review
• 2020-10-26: Program Update: generic deferiprone added as target, criteria updated to remove reference to brand products
• 2020-08-27: Program Update: added new GPI-93100028000345
• 2020-03-05: Annual Review
• 2019-09-20: Update to add new 1000 mg strength

---