Limited Coverage Drugs - Deferasirox


Generic Name                                                                                                                                                                                                         

deferasirox

Strength

Tablet, dispersible: 125 mg, 250 mg, 500 mg

Tablet, oral: 90 mg, 180 mg, 360 mg


Form

tablet (dispersible and oral)

Special Authority Criteria

Approval Period  

Treatment of transfusion-dependent conditions where iron chelation therapy is required, according to established criteria*, and when prescribed by a hematologist. Initial request: 1 year

Renewal request: 1 year

Practitioner Exemptions

  • No practitioner exceptions.

Special Notes

  • None

Special Authority Request Form(s)

* Click on the Special Authority Form below for full criteria: