Nplate (romiplostim) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• For HS-ARS: diagnosis confirmed
• For ITP: diagnosis of immune (idiopathic) thrombocytopenia AND
• If pediatric, ITP duration ≥ 6 months
• Platelet count ≤ 30 x 10^9/L OR 30–50 x 10^9/L with symptomatic bleeding or increased bleeding risk
• AND one of the following treatment histories:
• BOTH of the following: documentation of stage IV advanced metastatic cancer and use consistent with FDA-approved best practices OR
• Tried and inadequate response to ONE corticosteroid used for ITP OR
• Intolerance/hypersensitivity to ONE corticosteroid used for ITP OR
• FDA labeled contraindication to ALL corticosteroids used for ITP OR
• Tried and inadequate response to immunoglobulins (IVIg or anti-D) OR
• Inadequate response to splenectomy OR
• Tried and inadequate response to rituximab