Iron Chelating Agents - BMC HealthNet Plan

(demonstrated by at least 2 lab values in the previous 3 months);AND4. An absolute neutrophil count (ANC) >1.5 x 10 9 /L; AND5. The prescriber is a hematologist or oncologist.Continuation of TherapyExjade ® Documentation of the following:1. For chronic transfusional iron overload due to blood transfusions:Clinical response to treatment and continues to require therapy forserum ferritin level consistently >500mcg/L (demonstrated by atleast 2 lab values in the previous 3 months); OR2. For non-transfusion-dependent thalassemia (NTDT):Clinical response to treatment. (demonstrated by decreased liveriron levels in the previous 6 months compared to baseline but noless than 3mg/g, and serum ferritin level no less than 300mcg/Lwithin last month)Ferriprox ®Documentation of the following:1. Clinical response to treatment and continues to require therapy forserum ferritin level consistently >500mcg/L (demonstrated by atleast 2 lab values in the previous 3 months); AND2. An absolute neutrophil count (ANC) >1.5 x 10 9 /LLimitations:BMC HealthNet Plan will not approve coverage of Exjade ® , Ferriprox ® in the followinginstances:1. When the criteria above are not met.This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.BMC HealthNet Plan – Iron Chelating Agents4 of 6