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Nplate — Blue Cross Blue Shield of New Mexico

Thrombocytopenia in hepatitis C

Initial criteria

  • The patient has a baseline platelet count ≤ 30 × 10^9/L OR platelet count > 30 × 10^9/L and < 50 × 10^9/L with symptomatic bleeding and/or increased risk for bleeding
  • AND ONE of the following administration criteria: A. BOTH:  1. ONE of the following:   • The prescriber has stated or documented diagnosis of stage 4 advanced, metastatic cancer and the requested agent is being used to treat the cancer or an associated condition (chart notes required)  AND  2. Use is consistent with best practices, supported by peer‑reviewed, evidence‑based literature, and FDA‑approved OR B. The patient has tried and had inadequate response to ≥1 corticosteroid used for ITP OR C. The patient has intolerance or hypersensitivity to ≥1 corticosteroid for ITP OR D. The patient has an FDA‑labeled contraindication to all corticosteroids for ITP OR E. The patient has tried and had an inadequate response to immunoglobulins (IVIg or Anti‑D) OR F. The patient has had an inadequate response to a splenectomy OR G. The patient has tried and had an inadequate response to rituximab
  • OR The patient has another FDA‑labeled indication for the requested agent and route of administration
  • OR The patient has another indication that is supported in compendia for the requested agent and route of administration
  • For Tavalisse: The patient must have chronic (≥12 months) ITP meeting the same platelet thresholds and must have tried and had inadequate response or intolerance to corticosteroid or another thrombopoietin receptor agonist (Doptelet, Nplate, Promacta), immunoglobulin, splenectomy, or rituximab as applicable
  • The patient’s age is within FDA labeling for the requested indication or supported by evidence
  • The requested agent will not be used in combination with another program agent unless Nplate is used for HS‑ARS
  • The patient does not have any FDA‑labeled contraindications to the requested agent
  • Compendia allowed: AHFS, DrugDex level 1, 2A, or 2B, or NCCN 1, 2A, or 2B
  • Alternate approval for members residing in Ohio with Fully Insured or HIM Shop plan if:  • No FDA‑labeled contraindications  AND one of: another FDA‑labeled indication OR compendia‑supported indication OR two peer‑reviewed journal articles showing safe/effective use

Reauthorization criteria

  • The patient was previously approved through the plan’s Prior Authorization process
  • AND ONE of the following: A. Diagnosis of ITP and platelet count ≥ 50 × 10^9/L OR increase sufficient to avoid clinically significant bleeding OR B. Hepatitis C–associated thrombocytopenia with initiation or maintenance of interferon therapy and platelet count ≥ 90 × 10^9/L OR sufficient to initiate/maintain interferon therapy OR C. Another diagnosis with documented clinical benefit from the requested agent
  • The patient will not be using the requested agent in combination with another program agent
  • The patient has no FDA‑labeled contraindications
  • Compendia allowed: AHFS, DrugDex 1, 2A, or 2B, or NCCN 1, 2A, or 2B recommended use

Approval duration

initial 6–12 months (varies by drug/indication); renewal 6–12 months