Promacta — CareFirst (Caremark)

Initial criteria

• Member has had an inadequate response or intolerance to prior therapy with corticosteroids, immunoglobulins, or splenectomy
• Member has an untransfused platelet count prior to initiation of either less than 30×10^9/L OR 30×10^9/L to 50×10^9/L with symptomatic bleeding or risk factors for bleeding

Reauthorization criteria

• Authorization of 3 months may be granted if current platelet count <50×10^9/L and platelet count is not sufficient to prevent clinically important bleeding and member has not received maximal dose for ≥4 weeks
• Authorization of 12 months may be granted if current platelet count <50×10^9/L and is sufficient to prevent clinically important bleeding
• Authorization of 12 months may be granted if current platelet count 50×10^9/L–200×10^9/L
• Authorization of 12 months may be granted if current platelet count >200×10^9/L to ≤400×10^9/L and dosing will be adjusted to achieve a safe platelet count

Approval duration

initial 6 months; reauthorization 3–12 months per criteria