Doptelet — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis of chronic immune (idiopathic) thrombocytopenia (ITP) defined as lasting for at least 12 months
• 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:
• • Prescriber states patient has stage 4 advanced, metastatic cancer and requested agent used to treat the cancer; or documentation confirms use for condition related to stage 4 advanced metastatic cancer supported by evidence-based literature and FDA-approved use OR
• • Tried and had inadequate response to one corticosteroid used for treatment of ITP OR intolerance/hypersensitivity to one corticosteroid OR contraindication to all corticosteroids used for treatment of ITP OR
• • Tried and had inadequate response to another thrombopoietin receptor agonist (e.g., Nplate, Promacta) or Tavalisse OR
• • Tried and had inadequate response to immunoglobulins (IVIg or Anti-D) OR
• • Had inadequate response to splenectomy OR
• • Tried and had inadequate response to rituximab
• OR
• Diagnosis of thrombocytopenia with chronic liver disease AND baseline platelet count < 50 × 10^9/L