Alvaiz — Highmark
Persistent or chronic immune thrombocytopenia (ITP)
Preferred products
- generic eltrombopag olamine
Initial criteria
- age ≥ 6 years
- diagnosis of immune thrombocytopenia (ICD-10: D69.3) classified as chronic (duration > 12 months)
- insufficient response to ONE of the following: corticosteroid therapy OR immunoglobulin therapy OR insufficient response after splenectomy
- EITHER platelet count > 30 x 10^9/L to < 50 x 10^9/L WITH significant mucous membrane bleeding OR one risk factor for bleeding (e.g., hypertension, peptic ulcer disease, vigorous lifestyle) OR platelet count ≤ 30 x 10^9/L
- therapeutic failure, contraindication, or intolerance to plan-preferred generic eltrombopag olamine
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months