Nplate (romiplostim) — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of HS-ARS OR ITP
• For pediatric ITP: ITP duration ≥ 6 months
• For ITP: baseline platelet count ≤ 30 × 10^9/L OR 30–<50 × 10^9/L with symptomatic bleeding or increased risk for bleeding
• AND ONE of the following for ITP:
• • Use consistent with metastatic stage IV cancer approved conditions per FDA and literature OR
• • Tried and had inadequate response to ≥1 corticosteroid for ITP OR intolerance/hypersensitivity/contraindication to corticosteroid(s) OR inadequate response to immunoglobulins (IVIg or anti‑D) OR inadequate response to splenectomy OR inadequate response to rituximab