Doptelet (avatrombopag tablets) — Cigna

Initial criteria

• Patient has a platelet count < 30 x 10^9/L (< 30,000/mcL) OR Patient has a platelet count < 50 x 10^9/L (< 50,000/mcL) AND is at increased risk of bleeding
• Patient has tried at least ONE other therapy (e.g., systemic corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, eltrombopag olamine tablets or oral suspension [Promacta, generic], Alvaiz [eltrombopag choline tablets], Nplate [romiplostim subcutaneous injection], Tavalisse [fostamatinib tablets], or rituximab) OR patient has undergone splenectomy
• Medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• According to the prescriber, the patient demonstrates a beneficial clinical response (e.g., increased platelet counts, maintenance of platelet counts, and/or decreased frequency of bleeding episodes)
• Patient remains at risk for bleeding complications

Approval duration

initial 3 months; reauth 1 year