Nplate (romiplostim) — Blue Cross Blue Shield of Illinois

Initial criteria

• For HS-ARS: Diagnosis confirmed.
• For ITP: Diagnosis of immune (idiopathic) thrombocytopenia AND ALL of the following:
• - If pediatric, ITP present for ≥ 6 months
• - ONE of:
• • Baseline platelet count ≤ 30 x 10^9/L OR
• • Baseline platelet count >30 to <50 x 10^9/L with symptomatic bleeding or increased bleeding risk
• - ONE of the following:
• 1. BOTH:
• • Diagnosis of stage four advanced, metastatic cancer and agent used to treat cancer or associated condition, documented
• • Use consistent with best practices for cancer treatment, supported by evidence-based literature and FDA-approved
• OR
• 2. Tried and inadequate response to ONE corticosteroid for ITP OR
• 3. Intolerance or hypersensitivity to ONE corticosteroid OR
• 4. FDA labeled contraindication to ALL corticosteroids OR
• 5. Tried and inadequate response to immunoglobulins (IVIg or anti-D) OR
• 6. Inadequate response to splenectomy OR
• 7. Tried and inadequate response to rituximab