Alvaiz (eltrombopag choline tablets – Teva) — Cigna

Initial criteria

• Patient is age ≥ 6 years
• Patient meets ONE of the following (a or b): a) Patient has a platelet count < 30 x 10^9/L (< 30,000/mcL); OR b) Patient meets BOTH of the following [(1) and (2)]: (1) Patient has a platelet count < 50 x 10^9/L (< 50,000/mcL); AND (2) According to the prescriber, the patient is at an increased risk for bleeding
• Patient meets ONE of the following (a or b): a) Patient has tried at least one other therapy; OR b) Patient has undergone splenectomy
• The medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• According to the prescriber, the patient demonstrates a beneficial clinical response
• Patient remains at risk for bleeding complications

Approval duration

3 months initial, 1 year continuation