Mulpleta (lusutrombopag) — Highmark
Thrombocytopenia with chronic liver disease
Initial criteria
- age ≥ 18 years
- diagnosis of thrombocytopenia (ICD-10: D69.6) and chronic liver disease (ICD-10: K76.9)
- scheduled procedure documented
- platelet count < 50 x 10^9/L
Reauthorization criteria
- diagnosis of thrombocytopenia (ICD-10: D69.6) and chronic liver disease (ICD-10: K76.9)
- scheduled procedure documented
- platelet count < 50 x 10^9/L
Approval duration
1 month