Doptelet — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of chronic immune (idiopathic) thrombocytopenia (ITP) defined as lasting ≥ 12 months
• Platelet count ≤ 30×10^9/L OR platelet count >30×10^9/L but <50×10^9/L with symptomatic bleeding and/or increased risk for bleeding
• AND one of the following: (a) patient has stage IV advanced metastatic cancer and use consistent with best practices and FDA approval; OR (b) inadequate response, intolerance, or contraindication to at least one corticosteroid used for ITP; OR (c) inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse; OR (d) inadequate response to immunoglobulins (IVIg or Anti-D); OR (e) inadequate response to splenectomy; OR (f) inadequate response to rituximab
• OR
• Diagnosis of thrombocytopenia with chronic liver disease with baseline platelet count <50×10^9/L