Doptelet (avatrombopag maleate) — Blue Cross Blue Shield of New Mexico

Initial criteria

• The patient meets ONE of the following:
• A. Diagnosis of chronic (≥12 months) immune (idiopathic) thrombocytopenia (ITP) AND BOTH of the following:
• 1. ONE of the following baseline platelet count requirements:
• • Platelet count ≤30×10^9/L OR
• • Platelet count >30×10^9/L but <50×10^9/L AND patient has symptomatic bleeding and/or increased bleeding risk
• 2. ONE of the following treatment history or special circumstances:
• • The prescriber has stated or documented that the patient has stage 4 advanced, metastatic cancer and the agent is used to treat the cancer or an associated condition, and use is consistent with best practices and FDA approval OR
• • The patient has tried and had an inadequate response to ONE corticosteroid used for ITP OR
• • The patient has intolerance or hypersensitivity to ONE corticosteroid used for ITP OR
• • The patient has an FDA labeled contraindication to ALL corticosteroids used for ITP OR
• • The patient has tried and had inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse OR
• • The patient has tried and had inadequate response to immunoglobulins (IVIg or Anti-D) OR
• • The patient has had inadequate response to splenectomy OR
• • The patient has tried and had inadequate response to rituximab
• B. OR Diagnosis of thrombocytopenia with chronic liver disease AND BOTH of the following:
• • Baseline platelet count <50×10^9/L AND
• • (Additional criteria continue in next section of policy, not visible here)