Promacta — Blue Cross Blue Shield of Alabama

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review]. (Doptelet and Mulpleta for thrombocytopenia with chronic liver disease, AND Nplate for hematopoietic syndrome of acute radiation syndrome (HS-ARS) should always be reviewed under initial criteria.)
• AND ONE of the following:
• The patient has a diagnosis of immune (idiopathic) thrombocytopenia (ITP) AND ONE of the following:
• • The patient’s platelet count is ≥ 50 x 10^9/L OR
• • The patient’s platelet count has increased sufficiently to avoid clinically significant bleeding
• OR The patient has the diagnosis of hepatitis C associated thrombocytopenia AND BOTH of the following:
• • The patient will be initiating or maintaining hepatitis C therapy with interferon AND
• • ONE of the following: platelet count ≥ 90 x 10^9/L OR platelet count increased sufficiently to initiate or maintain interferon therapy
• OR The patient has a diagnosis other than ITP or hepatitis C associated thrombocytopenia AND has had clinical benefit with the requested agent
• AND The patient will NOT be using the requested agent in combination with another agent included in this program
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

thrombocytopenia in hepatitis C - 6 months; all other indications - 12 months