Limited Coverage Drugs – iron sucrose

Generic Name

iron sucrose

Strength

20 mg/mL

Form

vial

Special Authority Criteria

Approval Period

For the treatment of adult patients with iron deficiency anemia (IDA) who meet the following criteria:

  • Patient has a documented diagnosis of IDA confirmed by laboratory testing results (e.g., hemoglobin, ferritin, transferrin saturation)

AND

  • Either one of the following:
    • Patient has failed to respond to an adequate trial of at least one oral iron therapy, which requires a minimum of 4 weeks trial period

OR

  • Patient is intolerant to at least two oral iron therapies

OR

  • Patient has contraindication to oral iron therapy

AND

  • Iron isomaltoside must be administered in a setting where appropriate monitoring and management of hypersensitivity reactions can be provided to the patient

Initial: One course of treatment up to a maximum of 1,000 mg per course that must be filled within 28 days

Renewal: One course of treatment at a minimum of 4 weeks after the dispense of the initial dose

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)