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Nplate — Blue Cross Blue Shield of Texas

Hepatitis C associated thrombocytopenia

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 increased risk for bleeding
  • AND ONE of the following:
  • • The prescriber has stated or documented diagnosis of stage four advanced, metastatic cancer and requested agent is used to treat the cancer or associated condition AND the use is consistent with best practices and FDA approved OR
  • • The patient has tried and had an inadequate response to ONE corticosteroid used for treatment of ITP OR
  • • The patient has intolerance or hypersensitivity to ONE corticosteroid used for treatment of ITP OR
  • • The patient has an FDA labeled contraindication to ALL corticosteroids used for treatment of ITP OR
  • • The patient has tried and had an inadequate response to immunoglobulins (IVIg or Anti-D) OR
  • • The patient has had inadequate response to splenectomy OR
  • • The patient has tried and had an inadequate response to rituximab OR
  • • The patient has another FDA labeled indication for the requested agent and route of administration OR
  • • The patient has another indication supported in compendia for the requested agent and route of administration
  • If requested agent is Tavalisse, chronic ITP (≥12 months duration) must also be met AND one of the above response/inadequacy criteria including prior thrombopoietin receptor agonist (e.g., Doptelet, Nplate, Promacta) if applicable.
  • For all requests, the patient’s age is within FDA labeling for the indication OR supported by literature.
  • The patient will not use the requested agent in combination with another agent in this program unless Nplate is used for HS-ARS.
  • No FDA labeled contraindications to the requested agent.
  • Compendia allowed: AHFS, DrugDex 1, 2A, or 2B, or NCCN 1, 2A, or 2B recommended use.
  • Special Ohio plan provision: may approve if no contraindications AND indication is FDA labeled, compendia supported, or supported by 2 peer-reviewed journal articles.

Reauthorization criteria

  • The patient has been previously approved through the plan’s prior authorization process.
  • AND ONE of the following:
  • • For ITP: platelet count ≥ 50 x 10^9/L OR platelet count increased sufficiently to avoid clinically significant bleeding OR
  • • For hepatitis C-associated thrombocytopenia: maintaining or initiating interferon therapy AND platelet count ≥ 90 x 10^9/L OR sufficient to initiate/maintain HCV therapy OR
  • • For all other diagnoses: patient has had clinical benefit with the requested agent.
  • The patient will not be using the requested agent in combination with another program agent.
  • The patient does not have FDA labeled contraindications.
  • Compendia allowed: AHFS, DrugDex 1, 2A, or 2B, or NCCN 1, 2A, or 2B recommended use.

Approval duration

12 months (varies by plan and indication; ITP typically 2–12 months; HS-ARS 1 time; thrombocytopenia in chronic liver disease 1 month)