Doptelet — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ALL of the following:
• Diagnosis of chronic (lasting ≥ 12 months) immune (idiopathic) thrombocytopenia (ITP) AND BOTH of:
• • ONE of the following baseline platelet counts:
• – Baseline platelet count ≤ 30 × 10^9/L OR
• – Baseline platelet count > 30 × 10^9/L and < 50 × 10^9/L AND symptomatic bleeding and/or increased risk for bleeding
• AND
• • ONE of the following treatment history or conditions:
• 1. Prescriber has stated or documented stage IV advanced metastatic cancer and agent used to treat cancer or associated condition AND use consistent with best practices, supported by evidence-based literature, and FDA approved OR
• 2. Tried and had inadequate response to ONE corticosteroid used for treatment of ITP OR
• 3. Intolerance or hypersensitivity to ONE corticosteroid used for treatment of ITP OR
• 4. FDA labeled contraindication to ALL corticosteroids used for treatment of ITP OR
• 5. Tried and had inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse OR
• 6. Tried and had inadequate response to immunoglobulins (IVIg or Anti-D) OR
• 7. Had an inadequate response to splenectomy OR
• 8. Tried and had inadequate response to rituximab
• OR
• Diagnosis of thrombocytopenia with chronic liver disease AND ALL of:
• • Baseline platelet count < 50 × 10^9/L