Promacta (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 x 10^9/L OR on concomitant interferon therapy at risk for discontinuation due to thrombocytopenia
• For severe aplastic anemia: at least 2 baseline 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
• Either: first-line use with standard immunosuppressive therapy (ATG + cyclosporine) OR one of the following:
• Stage IV advanced metastatic cancer documentation and use consistent with FDA-approved, evidence-based 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 risk AND one of the following:
• Stage IV advanced metastatic cancer documentation and use consistent with FDA-approved practice OR
• Tried and inadequate response to ONE corticosteroid for ITP OR intolerance/hypersensitivity to ONE corticosteroid OR contraindication to ALL corticosteroids OR tried and inadequate response to IVIg or anti-D OR inadequate response to splenectomy OR tried and inadequate response to rituximab