Tavalisse (fostamatinib disodium hexahydrate tablets) — Cigna

Initial criteria

• Patient age ≥ 18 years; AND
• Patient meets ONE of the following (a or b): a) platelet count < 30 x 10^9/L (< 30,000/mcL); OR b) BOTH: (1) platelet count < 50 x 10^9/L (< 50,000/mcL); AND (2) prescriber attests patient is at increased risk of bleeding; AND
• Patient meets ONE of the following (a or b): a) has tried at least ONE other therapy (e.g., systemic corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, Promacta [eltrombopag], Nplate [romiplostim], Doptelet [avatrombopag], or rituximab); OR b) has undergone splenectomy; AND
• Medication is prescribed by or in consultation with a hematologist.

Reauthorization criteria

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

Approval duration

initial: 3 months; reauth: 1 year