Iron Chelating Agents - BMC HealthNet Plan

Clinical Background Information and References:1. Product Information. Exjade ® , deferasirox. Novartis PharmaceuticalsCorporation. East Hanover, New Jersey 07936. January 2013.2. Schrier, S, Bacon, B. Chelation therapy for iron overload states. UptoDate ®Accessed 2013 Feb; available from http://uptodate.com3. Kwiatkowski JL. Management of transfusional iron overload – differentialproperties and efficacy of iron chelating agents. Journal of Blood Medicine2011:2 135-149Policy History:Effective Date: 07/13/2006Date of Review/Revision03/13/2008 – P&T annual review, title changed from, “Oral Iron Chelating Agents” to“Exjade ® ”03/12/2009 – P&T annual review, no changes required.03/11/2010 – P&T annual review, no changes required03/10/2011 – P&T annual review, specified timeframe for lab values for initial therapyand added continuation of therapy criteria.07/14/2011 – policy applied to Commercial03/08/2012 – P&T annual review, added criteria for Ferriprox ® , modified continuation oftherapy criteria, title changed to “Iron Chelating Agents”Last Review Date: 03/14/2013 – P&T annual review, added initial and continuation oftherapy criteria for Exjade ® for treating non-transfusion-dependent thalassemiaNext Review Date: 03/13/2014Approval DatesRegulatory Approval: N/AInternal Approval:Initial approval by Pharmacy & Therapeutics Committee – July 13, 2006Authorizing entityThis 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 Agents5 of 6