Tavalisse (fostamatinib disodium hexahydrate) — CareFirst (Caremark)

Initial criteria

• Member has an inadequate response or intolerance to prior therapy (e.g., corticosteroids, immunoglobulins)
• Member has an untransfused platelet count at any point prior to the initiation of the requested medication of either of the following: less than 30x10^9/L; 30x10^9/L to 50x10^9/L with symptomatic bleeding (e.g., significant mucous membrane bleeding, gastrointestinal bleeding or trauma) or risk factors for bleeding (see Appendix)
• Medication must be prescribed by or in consultation with a hematologist
• Tavalisse will not be used concomitantly with thrombopoietin receptor agonists (e.g., Promacta, Alvaiz, Nplate, Doptelet, Mulpleta)

Reauthorization criteria

• Authorization of up to 12 weeks may be granted to members with current platelet count less than 50x10^9/L for whom the platelet count is not sufficient to prevent clinically important bleeding and who have not received the requested drug for at least 12 weeks
• Authorization of 12 months may be granted to members with current platelet count less than 50x10^9/L for whom the current platelet count is sufficient to prevent clinically important bleeding
• Authorization of 12 months may be granted to members with current platelet count of 50x10^9/L to 200x10^9/L
• Authorization of 12 months may be granted to members with current platelet count greater than 200x10^9/L to less than or equal to 400x10^9/L for whom Tavalisse dosing will be adjusted to achieve a platelet count sufficient to avoid clinically important bleeding

Approval duration

Initial: 12 weeks; Reauthorization: up to 12 months