Limited Use Note(s)

FERRIC DERISOMALTOSE100mg elemental iron/mL Inj Sol (Preservative-Free)

Reason For Use Code	Clinical Criteria
610	For the treatment of patients with Iron Deficiency Anemia (IDA) who meet ALL the following criteria: - Patient has documented diagnosis of IDA confirmed by laboratory testing results (e.g. hemoglobin, ferritin); AND - Patient's IDA has experienced a failure to respond, documented intolerance, or contraindication to an adequate trial (i.e. at least 4 weeks) of at least one oral iron therapy; AND - Patient does not have hemochromatosis or other iron storage disorders; AND - Monoferric is administered in a setting where appropriate monitoring and management of hypersensitivity reactions can be provided to the Patient.
	LU Authorization Period: 1 year

Reason For Use Code

Clinical Criteria

610

For the treatment of patients with Iron Deficiency Anemia (IDA) who meet ALL the following criteria: - Patient has documented diagnosis of IDA confirmed by laboratory testing results (e.g. hemoglobin, ferritin); AND - Patient's IDA has experienced a failure to respond, documented intolerance, or contraindication to an adequate trial (i.e. at least 4 weeks) of at least one oral iron therapy; AND - Patient does not have hemochromatosis or other iron storage disorders; AND - Monoferric is administered in a setting where appropriate monitoring and management of hypersensitivity reactions can be provided to the Patient.

LU Authorization Period: 1 year

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