Stimate (desmopressin acetate nasal spray) — CareFirst (Caremark)
Qualitative platelet disorders
Initial criteria
- For von Willebrand disease (Type 1, 2A, 2M, or 2N): Authorization of one month may be granted for treatment of mild or moderate type 1 and type 2A, 2M, or 2N VWD in members initiating therapy.
- For von Willebrand disease (Type 1, 2A, 2M, or 2N): Authorization of 12 months may be granted for treatment of mild or moderate type 1 and type 2A, 2M, or 2N VWD in members continuing therapy and demonstrating a response to an initial trial of Stimate.
- For hemophilia A: Authorization of 12 months may be granted for treatment of hemophilia A with factor VIII activity level greater than 5%.
- For qualitative platelet disorders: Authorization of 12 months may be granted for treatment of a qualitative platelet disorder.
- For acquired hemophilia A: Authorization of 12 months may be granted for treatment of acquired hemophilia A.
- For acquired von Willebrand syndrome: Authorization of 12 months may be granted for treatment of acquired von Willebrand syndrome.
Reauthorization criteria
- Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in Section II when the member is experiencing benefit from therapy (e.g., reduced frequency or severity of bleeds).
Approval duration
1 month initial for new von Willebrand disease therapy; 12 months for continuation or other indications