Promacta (eltrombopag) — Blue Cross Blue Shield of Montana

Initial criteria

• For hepatitis C associated thrombocytopenia: intent to increase platelet counts sufficiently to initiate interferon therapy with baseline platelet <75 × 10^9/L OR on interferon therapy and at risk of discontinuing due to thrombocytopenia
• For severe aplastic anemia: at least 2 baseline blood criteria (neutrophils <0.5 × 10^9/L, platelets <30 × 10^9/L, reticulocytes <60 × 10^9/L) AND 1 marrow criterion (severe hypocellularity <25% OR moderate 25–50% with hematopoietic cells <30% of residual cells) AND ONE of:
• • Use as first‑line therapy in combination with antithymocyte globulin [ATG] AND cyclosporine, OR
• • Use consistent with stage IV advanced metastatic cancer FDA‑approved condition, OR
• • Tried and inadequate response/intolerance/contraindication to BOTH ATG AND cyclosporine
• For persistent or chronic ITP (≥3 months): baseline platelet ≤30 × 10^9/L OR 30–<50 × 10^9/L with symptomatic bleeding/increased risk and ONE of:
• • Use consistent with stage IV metastatic cancer approved condition OR
• • Tried and had inadequate response to corticosteroid, immunoglobulin, splenectomy, or rituximab OR intolerance/contraindication as stated