Doptelet — Blue Cross Blue Shield of Kansas

Initial criteria

• Diagnosis of chronic immune (idiopathic) thrombocytopenia (ITP) (lasting ≥ 12 months) AND platelet count ≤ 30 x 10^9/L OR platelet count > 30 x 10^9/L and < 50 x 10^9/L with symptomatic bleeding or increased risk for bleeding AND ONE of the following: tried and inadequate response to ONE corticosteroid for ITP OR intolerance or hypersensitivity to ONE corticosteroid OR FDA labeled contraindication to ALL corticosteroids OR tried and inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse OR tried and inadequate response to immunoglobulin (IVIg or Anti-D) OR inadequate response to splenectomy OR tried and inadequate response to rituximab
• Diagnosis of thrombocytopenia with chronic liver disease AND platelet count < 50 x 10^9/L AND scheduled to undergo a procedure with an associated risk of bleeding (e.g., gastrointestinal endoscopy, liver biopsy, bronchoscopy, dental procedure) AND patient would require a platelet transfusion unless platelet counts are clinically increased from baseline prior to therapy