Promacta (eltrombopag) — Blue Cross Blue Shield of New Mexico

Initial criteria

• For hepatitis C–associated thrombocytopenia: ONE of the following:
• — Therapy intended to increase platelets to initiate interferon and baseline platelet count < 75 × 10^9/L
• — On concomitant interferon therapy and at risk of discontinuation due to thrombocytopenia
• For severe aplastic anemia: ALL of the following:
• — ≥2 baseline blood criteria (Neutrophils <0.5×10^9/L, Platelets <30×10^9/L, Reticulocyte count <60×10^9/L)
• — Marrow hypocellularity criteria: Severe (<25%) OR Moderate (25–50%) with <30% hematopoietic cells
• — ONE of the following: (A) First-line use with ATG + cyclosporine; OR (B) Documentation of stage 4 metastatic cancer use consistent with FDA-approved practice; OR (C) Inadequate response/intolerance/contraindication to both ATG and cyclosporine
• For chronic or persistent ITP (≥3 months): BOTH of the following:
• — Baseline platelet ≤30×10^9/L OR 30–50×10^9/L with bleeding or risk for bleeding
• — ONE of the following: Documentation of stage 4 metastatic cancer use consistent with evidence-based FDA-approved therapy; OR inadequate response/intolerance/contraindication to ONE corticosteroid, IVIg or anti-D, splenectomy, or rituximab
• OR the patient has another FDA-labeled or compendia-supported indication