Mulpleta (lusutrombopag) — CareFirst (Caremark)
Thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure
Initial criteria
- Prescribed by or in consultation with a hematologist, hepatologist, or gastroenterologist
- Member has an untransfused platelet count of less than 50x10^9/L taken within 14 days of the request
- Member is scheduled to undergo a procedure
- Mulpleta will not be used concomitantly with other thrombopoietin receptor agonists (e.g., Doptelet, Promacta, Alvaiz, Nplate) or spleen tyrosine kinase inhibitors (e.g., Tavalisse)
Reauthorization criteria
- Continuation of therapy, defined as use beyond the initial approval for the same procedure, is not approvable. All members requesting authorization due to a newly scheduled procedure must meet all requirements in the coverage criteria.
Approval duration
30 days