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Mulpleta — Blue Cross Blue Shield of Illinois

Severe aplastic anemia

Initial criteria

  • The patient has a baseline platelet count ≤ 30 × 10^9/L OR baseline platelet count > 30 × 10^9/L but < 50 × 10^9/L AND has symptomatic bleeding and/or increased risk for bleeding
  • The patient has tried and had an inadequate response to ONE corticosteroid used for the treatment of ITP OR intolerance/hypersensitivity OR FDA-labeled contraindication to corticosteroids
  • The patient has tried and had an inadequate response to immunoglobulins (IVIg or Anti-D), splenectomy, or rituximab
  • The prescriber has documented stage IV advanced metastatic cancer use consistent with FDA label and evidence-based literature
  • The patient has another FDA-labeled or compendia-supported indication for the requested agent
  • If Tavalisse is requested, the patient has chronic (≥ 12 months) ITP, appropriate baseline platelet criteria, and has had an inadequate response to corticosteroid, another thrombopoietin receptor agonist (e.g., Doptelet, Nplate, Promacta), immunoglobulins, splenectomy, or rituximab
  • The patient’s age is within or supported for the requested indication
  • The patient will NOT use the medication in combination with another agent in this program unless Nplate for HS-ARS
  • The patient does NOT have any FDA-labeled contraindications

Reauthorization criteria

  • The patient was previously approved for the requested agent through prior authorization
  • For ITP: platelet count ≥ 50 × 10^9/L OR platelet count increased sufficiently to avoid significant bleeding
  • For hepatitis C thrombocytopenia: patient initiating or maintaining interferon therapy AND platelet count ≥ 90 × 10^9/L OR increased sufficiently to initiate/maintain interferon therapy
  • For other indications: patient has had clinical benefit
  • The patient will NOT use the requested agent in combination with another agent in this program
  • The patient does NOT have any FDA-labeled contraindications

Approval duration

12 months (BCBSIL); others vary by indication: ITP 2–6 months, Hep C 3–6 months, chronic liver disease procedure 1–3 months, severe aplastic anemia 4–6 months, HS-ARS 1 time)