Promacta — CareFirst (Caremark)
Severe aplastic anemia – insufficient response to immunosuppressive therapy
Initial criteria
- Member has had an insufficient response to prior immunosuppressive therapy
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