Promacta — CareFirst (Caremark)

Initial criteria

• Requested drug will be used in combination with standard immunosuppressive therapy (e.g., horse antithymocyte globulin [h-ATG] and cyclosporine)

Reauthorization criteria

• Authorization of up to 16 weeks total if current platelet count <50×10^9/L and member has not received appropriately titrated therapy for ≥16 weeks
• Authorization of 12 months total if current platelet count <50×10^9/L and member is transfusion-independent
• Authorization of 12 months if current platelet count 50×10^9/L–200×10^9/L
• Authorization of 12 months if current platelet count >200×10^9/L to ≤400×10^9/L and dosing will be adjusted to maintain an appropriate platelet count

Approval duration

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