Alvaiz — Blue Cross Blue Shield of Alabama

Initial criteria

• - Hepatitis C associated thrombocytopenia AND:
• • Platelet <75×10^9/L if goal to initiate interferon OR currently on interferon at risk to discontinue due to thrombocytopenia
• - OR severe aplastic anemia AND:
• • ≥2 of: neutrophils <0.5×10^9/L, platelets <30×10^9/L, reticulocytes <60×10^9/L
• • Bone marrow: severe (<25%) or moderate (25–50%) cellularity with hematopoietic cells <30% residual
• • ONE of: inadequate response to BOTH ATG and cyclosporine, intolerance/hypersensitivity to BOTH, or contraindication to BOTH
• - OR persistent/chronic (≥3 months) ITP AND:
• • Platelet ≤30×10^9/L OR platelet >30×10^9/L but <50×10^9/L with symptomatic bleeding or increased bleeding risk
• • ONE of: tried/inadequate response or intolerance/contraindication to corticosteroid; tried/inadequate response to IVIg or Anti-D; inadequate response to splenectomy; tried/inadequate response to rituximab
• - OR another FDA labeled or compendia-supported indication