Promacta (eltrombopag olamine) — Highmark
severe aplastic anemia – insufficient response to immunosuppressive therapy
Preferred products
- generic eltrombopag olamine
Initial criteria
- diagnosis of severe aplastic anemia (ICD-10: D61.9)
- insufficient response to at least one immunosuppressive therapy (e.g., antithymocyte globulin, cyclosporine, corticosteroids, or cyclophosphamide)
- platelet count < 30 x 10^9/L
- if request is for brand Promacta, therapeutic failure or intolerance to generic eltrombopag olamine