Tavalisse (fostamatinib) — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of chronic immune thrombocytopenia (ITP) with duration > 12 months (ICD-10: D69.3)
• ONE of the following: 1) insufficient response to corticosteroid therapy OR immunoglobulin therapy OR 2) insufficient response after splenectomy
• ONE of the following: 1) platelet count > 30 x 10^9/L to < 50 x 10^9/L AND (significant mucous membrane bleeding OR one risk factor for bleeding such as hypertension, peptic ulcer disease, vigorous lifestyle) OR 2) platelet count ≤ 30 x 10^9/L

Reauthorization criteria

• prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

12 months