Alvaiz — CareFirst (Caremark)

Initial criteria

• Member has had an insufficient response to immunosuppressive therapy

Reauthorization criteria

• Authorization of up to 16 weeks total may be granted to members with current platelet count less than 50×10^9/L who have not received appropriately titrated therapy for at least 16 weeks
• Authorization of 12 months total may be granted to members with current platelet count less than 50×10^9/L who are transfusion‑independent
• Authorization of 12 months may be granted to members with current platelet count of 50×10^9/L to 200×10^9/L
• Authorization of 12 months may be granted to members with current platelet count greater than 200×10^9/L to ≤400×10^9/L for whom dosing will be adjusted to achieve and maintain an appropriate target platelet count

Approval duration

6 months initial; up to 16 weeks or 12 months continuation per platelet response