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Transfusions Yes No Does the patient have a platelet count less than 50 x 10 9 /L age-appropriate upper limit of normal or is the creatinine clearance less than 40 mL/min Yes No Does the member have severe hepatic impairment Child-Pugh Class C Yes No Is being prescribed by a Hematologist Yes No Will baseline serum ferritin level be performed prior to the initiation of Please document serum ferritin level Page 1 of 2 10. If you do not obtain your prescriber s support for an expedited request...

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