By Counterforce Health Team in Ferriprox (deferiprone) —

The Requirements Checklist to Get Ferriprox (Deferiprone) Covered by Aetna (CVS Health) in Ohio: Complete Guide with Forms and Appeals

Answer Box: Getting Ferriprox (Deferiprone) Covered by Aetna (CVS Health) in Ohio

Fastest path to approval: Submit prior authorization through Aetna's pharmacy benefit with documented transfusional iron overload (ferritin >1,000 mcg/L), step therapy failure/intolerance to deferasirox or deferoxamine, and weekly ANC monitoring plan. First step today: Call Aetna member services (number on your card) to confirm formulary status and PA requirements. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance after exhausting internal appeals.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking and Follow-up
  9. Denial Prevention Tips
  10. Ohio Appeals Process
  11. Quick Reference Checklist

Who Should Use This Checklist

This comprehensive checklist is designed for Ohio patients with Aetna (CVS Health) coverage who need Ferriprox (deferiprone) for transfusional iron overload, along with their healthcare providers and caregivers.

Use this guide if you have:

  • Thalassemia syndromes, sickle cell disease, or other chronic anemias requiring regular transfusions
  • Documented iron overload with ferritin levels above 1,000 mcg/L
  • Failed or cannot tolerate other iron chelators like deferasirox (Exjade/Jadenu) or deferoxamine (Desferal)
  • Aetna commercial, Medicare Advantage, or marketplace coverage in Ohio

Expected outcome: Following this checklist significantly improves your chances of first-time approval and helps you navigate Ohio's appeals process if initially denied. Counterforce Health specializes in turning insurance denials into successful appeals by providing evidence-backed documentation that aligns with payer-specific requirements.

Member & Plan Basics

Coverage Verification

Before starting your prior authorization request, confirm these essential details:

Requirement What to Verify How to Check
Active Coverage Your Aetna plan is current and premiums paid Member portal or call member services
Pharmacy Benefit Ferriprox covered under pharmacy (not medical) Aetna formulary search
Prior Authorization PA required for all Ferriprox requests Check Aetna PA requirements
Step Therapy Must try other chelators first Review your specific plan documents
Tip: Aetna typically processes Ferriprox through CVS Caremark for pharmacy benefits and CVS Specialty for dispensing once approved.

Clinical Criteria Requirements

FDA-Approved Indications

Ferriprox must be prescribed for transfusional iron overload in patients with:

  • Thalassemia syndromes (including β-thalassemia major)
  • Sickle cell disease
  • Other chronic anemias requiring regular blood transfusions

Age and Formulation Requirements

Formulation Minimum Age Maximum Dose
Tablets 8 years and older 99 mg/kg/day divided TID
Oral Solution 3 years and older 99 mg/kg/day divided TID

Laboratory Thresholds

Required baseline values:

  • Serum ferritin >1,000 mcg/L (within 30-90 days of request)
  • Absolute neutrophil count (ANC) documented before starting
  • Liver function tests (ALT, AST, bilirubin)

Step Therapy Requirements

Most Aetna plans require documented failure, inadequate response, or contraindication to:

  1. Deferasirox (Exjade/Jadenu) - first-line oral chelator
  2. Deferoxamine (Desferal) - injectable chelator option

Documentation must include:

  • Drug name, dose, duration of trial
  • Specific adverse effects or medical contraindications
  • Clinical rationale for switching to Ferriprox

Coding and Documentation

ICD-10 Diagnosis Codes

Primary Diagnosis ICD-10 Code When to Use
Transfusional iron overload E83.111 Hemochromatosis due to repeated RBC transfusions
Beta thalassemia D56.1x Specify variant (major, intermedia, etc.)
Sickle cell disease D57.1 Without crisis; use D57.0x for with crisis
Iron overload, unspecified E83.1 When etiology unclear but iron burden documented

HCPCS and Billing

Ferriprox is typically billed using NDC numbers through the pharmacy benefit rather than HCPCS J-codes. For medical benefit billing (rare), use:

  • J3490 (unclassified drug) with NDC, strength, and units
  • Include complete drug information and administration details

Documentation Packet Essentials

Provider Note Requirements

Your prescriber's documentation must include:

Diagnosis and History:

  • Specific underlying condition (thalassemia, sickle cell disease)
  • Transfusion history: frequency, total units, duration
  • Current symptoms or complications from iron overload

Laboratory Evidence:

  • Recent ferritin level >1,000 mcg/L with date
  • Baseline ANC and complete blood count
  • Liver iron concentration (LIC) by MRI if available
  • Cardiac T2* MRI if cardiac iron overload suspected

Prior Treatment History:

  • Previous chelators tried (names, doses, duration)
  • Specific reasons for discontinuation or failure
  • Adverse effects experienced with each agent

Medical Necessity Letter Components

A strong letter should address:

  1. Clear indication: Transfusional iron overload with objective evidence
  2. Treatment failure: Documented inadequate response or intolerance to preferred agents
  3. Clinical rationale: Why Ferriprox is medically necessary now
  4. Safety monitoring: Detailed ANC monitoring plan
  5. Treatment goals: Target ferritin levels and expected outcomes
Clinician Corner: Use Chiesi's medical necessity templates as a starting point, then customize with patient-specific details and payer requirements.

Required Attachments

  • Recent laboratory reports (ferritin, CBC with ANC, liver function)
  • Transfusion records or summary
  • Prior chelator trial documentation
  • Current clinic notes documenting iron overload complications
  • Aetna PA form completed

Submission Process

Correct Forms and Portals

Primary submission method: Electronic PA through CVS Caremark portal or standard ePA platforms (Surescripts, CoverMyMeds)

Alternative methods:

  • Fax: Use Aetna's PA form to specialty PA fax number
  • Phone: 1-855-240-0535 for urgent/expedited requests

Common Rejection Points

Avoid these frequent submission errors:

  • Missing ANC monitoring plan details
  • Incomplete step therapy documentation
  • Ferritin level older than 90 days
  • Incorrect age/formulation combination
  • Missing prescriber DEA or NPI numbers

Specialty Pharmacy Routing

CVS Specialty Process

Once approved, Ferriprox is typically dispensed through CVS Specialty Pharmacy:

  1. Automatic transfer: CVS Caremark routes approved prescriptions to CVS Specialty
  2. Patient contact: CVS Specialty calls patient to coordinate delivery
  3. Monitoring support: Ongoing adherence and lab monitoring reminders

Verification Steps

  • Confirm specialty pharmacy assignment in approval letter
  • Verify shipping address and preferred delivery times
  • Review storage requirements (room temperature, protect from moisture)
  • Set up automatic refill schedule aligned with lab monitoring

After Submission: Tracking and Follow-up

Timeline Expectations

Review Type Decision Timeframe Ohio Requirements
Standard PA 15 business days Per Aetna policy
Expedited/Urgent 72 hours When delay risks health
Appeals 30 days internal Ohio external review available

Status Monitoring

Track your request:

  • Document PA reference number and submission date
  • Check status weekly through provider portal
  • Follow up if no decision within expected timeframe
  • Request written denial with specific reasons if rejected

Denial Prevention Tips

Five Common Pitfalls and Solutions

  1. Insufficient step therapy documentation
    • Solution: Provide detailed trial history with specific adverse effects and dates
  2. Missing ANC monitoring plan
    • Solution: Include explicit weekly monitoring schedule and neutropenia management protocol
  3. Outdated ferritin levels
    • Solution: Submit labs within 30 days of PA request
  4. Vague medical necessity
    • Solution: Link iron overload directly to transfusion history and organ damage risk
  5. Incomplete prior authorization form
    • Solution: Double-check all required fields and attach supporting documentation

Proactive Strategies

When working with Counterforce Health, we've seen that successful Ferriprox approvals consistently include comprehensive step therapy documentation and detailed ANC monitoring protocols that address Aetna's specific safety requirements.

Ohio Appeals Process

Internal Appeals with Aetna

If your initial PA is denied:

  1. Request peer-to-peer review within 5 business days
  2. File formal internal appeal within 60 days of denial
  3. Submit additional documentation addressing specific denial reasons
  4. Request expedited review if clinically urgent

Ohio External Review

Ohio residents have strong appeal rights through the Ohio Department of Insurance (ODI):

Timeline: 180 days from final Aetna denial to request external review Process: Submit request through Aetna (not directly to ODI) Cost: Free to consumers Decision timeframe: 30 days standard, 72 hours expedited

ODI Consumer Assistance: 1-800-686-1526 for help with appeals process

When to Escalate

Contact ODI if:

  • Aetna claims your case isn't eligible for external review
  • Internal appeal deadlines are not met
  • You need help understanding your appeal rights
  • Aetna doesn't follow Ohio external review requirements
From our advocates: We've seen Ohio external reviews successfully overturn Aetna specialty drug denials when the clinical documentation clearly demonstrates medical necessity and step therapy compliance. The key is providing comprehensive evidence that directly addresses the original denial reasons.

Quick Reference Checklist

Before Submitting PA

  • Confirm active Aetna coverage and pharmacy benefit
  • Verify Ferriprox formulary status and PA requirements
  • Gather recent ferritin >1,000 mcg/L (within 30 days)
  • Document baseline ANC and safety labs
  • Compile step therapy failure/intolerance documentation
  • Complete medical necessity letter addressing Aetna criteria

Documentation Packet

  • Completed Aetna PA form
  • Medical necessity letter with ANC monitoring plan
  • Recent laboratory reports (ferritin, CBC, liver function)
  • Transfusion history summary
  • Prior chelator trial documentation
  • Current clinic notes documenting iron overload

After Submission

  • Record PA reference number and submission date
  • Set calendar reminders for status checks
  • Prepare appeal documentation if needed
  • Contact CVS Specialty once approved
  • Schedule baseline labs before starting therapy

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage requirements and should not be considered medical advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance company. For personalized assistance with prior authorizations and appeals, consider consulting with coverage specialists who understand payer-specific requirements and can help optimize your documentation for success.

Ohio residents seeking additional help with health insurance appeals can contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526 or visit insurance.ohio.gov for official resources and forms.

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