Iron Chelators

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PDL Reference Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00591473530 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
00591473554 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
31722003031 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
31722003032 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
42806037230 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
67877067672 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
67877067684 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
69097056031 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
69097056053 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
72205007530 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
72205007561 DEFERASIROX deferasirox GRAN PACK 180 mg N Y N  
00078071315 JADENU SPRINKLE deferasirox GRAN PACK 180 mg N Y N  
00078071319 JADENU SPRINKLE deferasirox GRAN PACK 180 mg N Y N  
00591474030 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
00591474054 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
31722003131 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
31722003132 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
42806037330 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
67877067773 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
67877067784 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
69097057031 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
69097057053 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
72205007630 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
72205007661 DEFERASIROX deferasirox GRAN PACK 360 mg N Y N  
00078072015 JADENU SPRINKLE deferasirox GRAN PACK 360 mg N Y N  
00078072019 JADENU SPRINKLE deferasirox GRAN PACK 360 mg N Y N  
00591473030 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
00591473054 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
31722002932 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
42806037130 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
67877067571 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
67877067584 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
69097055031 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
69097055053 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
72205017630 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
72205017661 DEFERASIROX deferasirox GRAN PACK 90 mg N Y N  
00078072715 JADENU SPRINKLE deferasirox GRAN PACK 90 mg N Y N  
00078072719 JADENU SPRINKLE deferasirox GRAN PACK 90 mg N Y N  
00480701156 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
45963045430 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
62332032430 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
62756056883 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
67877054930 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
69452015913 DEFERASIROX deferasirox TAB DISPER 125 mg N Y N  
00078046815 EXJADE deferasirox TAB DISPER 125 mg N Y N  
00480701256 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
45963045530 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
62332032530 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
62756056983 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
67877055030 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
69452016013 DEFERASIROX deferasirox TAB DISPER 250 mg N Y N  
00078046915 EXJADE deferasirox TAB DISPER 250 mg N Y N  
00480701356 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
45963045630 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
62332032630 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
62756057083 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
67877055130 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
69452016113 DEFERASIROX deferasirox TAB DISPER 500 mg N Y N  
00078047015 EXJADE deferasirox TAB DISPER 500 mg N Y N  
31722001230 DEFERASIROX deferasirox TABLET 180 mg N Y N  
43598085230 DEFERASIROX deferasirox TABLET 180 mg N Y N  
59651041130 DEFERASIROX deferasirox TABLET 180 mg N Y N  
62332041130 DEFERASIROX deferasirox TABLET 180 mg N Y N  
70700027030 DEFERASIROX deferasirox TABLET 180 mg N Y N  
70710127603 DEFERASIROX deferasirox TABLET 180 mg N Y N  
72603023201 DEFERASIROX deferasirox TABLET 180 mg N Y N  
00078065515 JADENU deferasirox TABLET 180 mg N Y N  
31722001330 DEFERASIROX deferasirox TABLET 360 mg N Y N  
43598085130 DEFERASIROX deferasirox TABLET 360 mg N Y N  
59651041230 DEFERASIROX deferasirox TABLET 360 mg N Y N  
62332041230 DEFERASIROX deferasirox TABLET 360 mg N Y N  
67877055430 DEFERASIROX deferasirox TABLET 360 mg N Y N  
70700027130 DEFERASIROX deferasirox TABLET 360 mg N Y N  
70710127703 DEFERASIROX deferasirox TABLET 360 mg N Y N  
72603023301 DEFERASIROX deferasirox TABLET 360 mg N Y N  
00078065615 JADENU deferasirox TABLET 360 mg N Y N  
31722001130 DEFERASIROX deferasirox TABLET 90 mg N Y N  
43598085330 DEFERASIROX deferasirox TABLET 90 mg N Y N  
59651041030 DEFERASIROX deferasirox TABLET 90 mg N Y N  
62332041030 DEFERASIROX deferasirox TABLET 90 mg N Y N  
67877055230 DEFERASIROX deferasirox TABLET 90 mg N Y N  
70700026930 DEFERASIROX deferasirox TABLET 90 mg N Y N  
70710127503 DEFERASIROX deferasirox TABLET 90 mg N Y N  
72603023101 DEFERASIROX deferasirox TABLET 90 mg N Y N  
00078065415 JADENU deferasirox TABLET 90 mg N Y N  
10122010150 FERRIPROX deferiprone SOLUTION 100 mg/mL N Y N  
00054071119 DEFERIPRONE (3 TIMES A DAY) deferiprone TABLET 1,000 mg N Y N  
51672423704 DEFERIPRONE (3 TIMES A DAY) deferiprone TABLET 1,000 mg N Y N  
10122010305 FERRIPROX (3 TIMES A DAY) deferiprone TABLET 1,000 mg N Y N  
00054057625 DEFERIPRONE deferiprone TABLET 500 mg N Y N  
51672419601 DEFERIPRONE deferiprone TABLET 500 mg N Y N  
10122010010 FERRIPROX deferiprone TABLET 500 mg N Y N  
10122010401 FERRIPROX (2 TIMES A DAY) deferiprone TABLET MR 1,000 mg N Y N  
10122010405 FERRIPROX (2 TIMES A DAY) deferiprone TABLET MR 1,000 mg N Y N  
00409233715 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
00409233725 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
47781062407 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
60505623700 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
60505623706 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
63323059930 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 2 gram Y Y N  
60505623600 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
60505623606 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
60505623800 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
60505623806 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
63323059710 DEFEROXAMINE MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
00078046761 DESFERAL MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
00078046791 DESFERAL MESYLATE deferoxamine mesylate VIAL 500 mg Y Y N  
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