Nplate (romiplostim) — Blue Cross Blue Shield of New Mexico

Initial criteria

• For HS-ARS: diagnosis confirmed
• For ITP: ALL of the following apply:
• If pediatric, ITP duration ≥ 6 months
• Baseline platelet count ≤ 30 × 10^9/L OR 30–50 × 10^9/L with symptomatic bleeding or increased bleeding risk
• AND ONE of the following response situations:
• (A) BOTH: (1) documentation of stage 4 metastatic cancer with therapeutic use consistent with FDA-approved, evidence-based practice, OR (2) The patient has tried and had an inadequate response/intolerance/contraindication to prior treatments: ONE corticosteroid for ITP OR immunoglobulin therapy OR splenectomy OR rituximab
• OR the patient has another FDA-labeled indication for the agent and route
• OR the patient has another indication supported in compendia for the agent and route