Doptelet (avatrombopag) — CareFirst (Caremark)
Immune thrombocytopenia (ITP)
Initial criteria
- Member has had an inadequate response or intolerance to prior therapy (e.g., corticosteroids, immunoglobulins)
- Member has an untransfused platelet count at any point prior to initiation of the requested medication of either of the following: less than 30x10^9/L OR 30x10^9/L to 50x10^9/L with symptomatic bleeding (e.g., significant mucous membrane bleeding, gastrointestinal bleeding or trauma) or risk factors for bleeding
Reauthorization criteria
- Authorization of 3 months may be granted to members with current platelet count less than 50x10^9/L for whom the platelet count is not sufficient to prevent clinically important bleeding and who have not received a maximal Doptelet dose for at least 4 weeks
- Authorization of 12 months may be granted to members with current platelet count less than 50x10^9/L for whom the current platelet count is sufficient to prevent clinically important bleeding
- Authorization of 12 months may be granted to members with current platelet count of 50x10^9/L to 200x10^9/L
- Authorization of 12 months may be granted to members with current platelet count greater than 200x10^9/L to less than or equal to 400x10^9/L for whom Doptelet dosing will be adjusted to achieve a platelet count sufficient to avoid clinically important bleeding
Approval duration
Initial: 6 months; Continuation: 3–12 months depending on platelet count