Alvaiz — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The patient has a baseline platelet count ≤ 30 x 10^9/L OR baseline platelet count > 30 x 10^9/L but < 50 x 10^9/L AND has symptomatic bleeding and/or an increased risk for bleeding
• AND ONE of the following: (1) BOTH of the following: (a) The prescriber has stated or documented diagnosis of stage four advanced, metastatic cancer and requested agent used to treat the cancer or associated condition; AND (b) The use is consistent with best practices, supported by peer-reviewed, evidence-based literature, and FDA approved OR (2) The patient has tried and had inadequate response to ONE corticosteroid used for ITP OR (3) The patient has intolerance/hypersensitivity to ONE corticosteroid used for ITP OR (4) The patient has FDA labeled contraindication to ALL corticosteroids used for ITP OR (5) The patient has tried and had inadequate response to immunoglobulins (IVIg or Anti-D) OR (6) The patient has had inadequate response to a splenectomy OR (7) The patient has tried and had inadequate response to rituximab
• The patient has another FDA labeled indication for the requested agent and route of administration OR indication supported in compendia
• If requested agent is Tavalisse: patient must have chronic (≥ 12 months) immune (idiopathic) thrombocytopenia, same platelet count and bleeding criteria, and must have tried and inadequately responded to corticosteroid, another thrombopoietin receptor agonist (e.g., Doptelet, Nplate, Promacta), immunoglobulins (IVIg or Anti-D), splenectomy, or rituximab
• If patient has FDA approved indication, age is within FDA labeling OR supported by evidence for that age
• Patient will not use requested agent in combination with another agent in the program EXCEPT Nplate may be used with diagnosis of HS-ARS
• Patient does not have any FDA labeled contraindications to requested agent
• Compendia Allowed: AHFS, DrugDex 1, 2A, or 2B; NCCN 1, 2A, or 2B
• For members in Ohio with Fully Insured or HIM Shop plans: approval if no contraindications AND (another FDA labeled indication OR indication supported in compendia OR provider submits two peer-reviewed journal studies supporting safe/effective use)

Reauthorization criteria

• The patient was previously approved for the requested agent through prior authorization process
• For ITP: platelet count ≥ 50 x 10^9/L OR increased sufficiently to avoid clinically significant bleeding
• For hepatitis C associated thrombocytopenia: will initiate or maintain interferon therapy AND (platelet count ≥ 90 x 10^9/L OR platelet count increased sufficiently to initiate or maintain interferon therapy)
• For other diagnoses: patient has had clinical benefit with the requested agent
• The patient will not use the requested agent in combination with another agent in this program
• The patient does not have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS, DrugDex 1, 2A, or 2B; NCCN 1, 2A, or 2B

Approval duration

BCBSIL 12 months; BCBSMT/BCBSNM/others per table: Doptelet (1–12 months), Mulpleta (1–12 months), Promacta (2–12 months), Nplate (1 time–12 months), Tavalisse (6–12 months), Alvaiz (2–12 months)