Alvaiz (eltrombopag) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• For hepatitis C thrombocytopenia: intent to increase platelet counts to initiate interferon therapy AND baseline platelet < 75 x10^9/L OR concomitant interferon therapy with risk of discontinuation
• For severe aplastic anemia: at least 2 blood criteria (neutrophils <0.5x10^9/L, platelets <30x10^9/L, reticulocytes <60x10^9/L) AND one marrow criterion (severe hypocellularity <25% or moderate hypocellularity 25–50% with hematopoietic cells <30%) AND one of the following:
• Stage IV advanced metastatic cancer documentation and use consistent with FDA-approved, evidence-based best practices OR
• Tried and inadequate response to BOTH ATG and cyclosporine OR intolerance/hypersensitivity to BOTH OR FDA labeled contraindication to BOTH
• For ITP: persistent/chronic ITP ≥ 3 months with platelet ≤30x10^9/L OR 30–50x10^9/L with symptomatic bleeding/increased bleeding risk