Doptelet — Blue Cross Blue Shield of Illinois

Initial criteria

• ALL of the following:
• 1. For chronic immune (idiopathic) thrombocytopenia (ITP):
• A. Disease duration ≥ 12 months; AND
• B. ONE of the following baseline platelet count criteria:
• • Platelet count ≤ 30 × 10^9/L; OR
• • Platelet count > 30 × 10^9/L but < 50 × 10^9/L with symptomatic bleeding and/or increased bleeding risk; AND
• C. ONE of the following treatment criteria:
• • The prescriber states or provides documentation that the patient has stage 4 advanced, metastatic cancer and the requested agent is being used to treat the cancer or a related condition AND the use is consistent with best practices, supported by evidence-based literature, and FDA approved; OR
• • The patient has tried and had an inadequate response to ONE corticosteroid used for ITP; OR
• • The patient has an intolerance or hypersensitivity to ONE corticosteroid used for ITP; OR
• • The patient has an FDA-labeled contraindication to ALL corticosteroids used for ITP; OR
• • The patient has tried and had an inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse; OR
• • The patient has tried and had an inadequate response to immunoglobulins (IVIg or Anti-D); OR
• • The patient has had an inadequate response to a splenectomy; OR
• • The patient has tried and had an inadequate response to rituximab.
• 2. For thrombocytopenia with chronic liver disease:
• A. Baseline platelet count < 50 × 10^9/L.