Promacta (eltrombopag) — Blue Cross Blue Shield of Illinois

Initial criteria

• For hepatitis C associated thrombocytopenia: ONE of:
• - Intent to increase platelet counts to initiate interferon therapy AND baseline platelet count <75 x 10^9/L OR
• - On concomitant interferon therapy and at risk for discontinuation due to thrombocytopenia
• For severe aplastic anemia: ALL of:
• - At least two of: neutrophils <0.5 x 10^9/L, platelets <30 x 10^9/L, reticulocyte count <60 x 10^9/L
• - ONE marrow criterion: severe hypocellularity (<25%) OR moderate (25–50%) with hematopoietic cells <30% of residual cells
• - ONE of:
• • BOTH: first-line use in combination with ATG and cyclosporine OR
• • BOTH:
• – Diagnosis of stage four advanced, metastatic cancer and agent used to treat related condition, documented
• – Use consistent with best practices and FDA-approved OR
• • Tried and inadequate response to BOTH ATG AND cyclosporine OR
• • Intolerance or hypersensitivity to BOTH ATG AND cyclosporine OR
• • FDA labeled contraindication to BOTH ATG AND cyclosporine
• For persistent or chronic ITP (≥3 months): BOTH:
• - ONE of:
• • Baseline platelet count ≤ 30 x 10^9/L OR
• • Platelet count >30 to <50 x 10^9/L with symptomatic bleeding or increased bleeding risk
• - ONE of:
• • BOTH: stage four metastatic cancer documentation and best practice use criteria OR
• • Tried and inadequate response to ONE corticosteroid OR
• • Intolerance or hypersensitivity to ONE corticosteroid OR
• • FDA labeled contraindication to ALL corticosteroids OR
• • Tried and inadequate response to immunoglobulins (IVIg or anti-D) OR
• • Inadequate response to splenectomy OR
• • Tried and inadequate response to rituximab