Promacta (eltrombopag olamine) — Highmark
persistent or chronic immune thrombocytopenia (ITP)
Preferred products
- generic eltrombopag olamine
Initial criteria
- age ≥ 1 year
- diagnosis of immune thrombocytopenia (ICD-10: D69.3) classified as chronic (duration > 12 months)
- insufficient response to corticosteroid therapy OR immunoglobulin therapy OR insufficient response after splenectomy
- platelet count > 30 x 10^9/L and < 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
- if request is for brand Promacta, therapeutic failure or intolerance to generic eltrombopag olamine