Alvaiz — Highmark
Severe aplastic anemia with insufficient response to immunosuppressive therapy
Preferred products
- generic eltrombopag olamine
Initial criteria
- diagnosis of severe aplastic anemia (ICD-10: D61.9)
- insufficient response to ONE immunosuppressive therapy (e.g., antithymocyte globulin, cyclosporine, corticosteroids, cyclophosphamide)
- 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