Product Details

Ferriprox

Deferiprone
1000 mg
Tablet


DIN/PIN/NPN

02436558

Manufacturer

Chiesi Canada Corp.

Formulary Listing Date

2021-04-22  

Unit Price

33.4740

Amount MOH Pays

25.1055

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

V03AC02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02436558 Ferriprox 33.4740 25.1055
02553112 Taro-Deferiprone 25.1055 25.1055
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Blood Modifiers

Deferiprone

  • Brand(s): Ferriprox
  • Dosage Form/Strength: 1000 mg Tablets, 100 mg/mL oral solution

For the treatment of patients with transfusional iron overload due to thalassemia syndromes who cannot be adequately treated with deferoxamine or deferasirox. 

Notes: 

  • Combination iron chelation therapy with Ferriprox will be considered on a case-by-case basis.

  • Therapy should be initiated and maintained by physicians experienced in the treatment of chronic iron overload due to blood transfusions. 

Duration of Approval: 5 years 

Renewals will be considered for Patients who continue to require iron chelation therapy and has had a consistent response to therapy (demonstrated by a reduction in baseline liver iron concentration (LIC) levels). 

The following documentation is required: 

  • A transfusion record from the past year; and 

  • LIC levels – baseline (pre-treatment) and since initiation of treatment. The most recent LIC level should be from within the previous year.

Duration of Approval: 5 years

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph