Alvaiz (eltrombopag choline tablets – Teva) — Cigna

Initial criteria

• Patient is age ≥ 18 years
• Patient has low platelet counts at baseline (pretreatment)
• Patient meets ONE of the following (a or b): a) Patient had tried at least one immunosuppressant therapy; OR b) Patient will be using eltrombopag in combination with standard immunosuppressive therapy
• The medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• According to the prescriber, the patient demonstrates a beneficial clinical response

Approval duration

4 months initial, 1 year continuation