Promacta tablets (brand) — Medica
any FDA-approved indication(s) per standard Thrombocytopenia – Eltrombopag Products Prior Authorization Policy
Preferred products
- generic eltrombopag tablets
Initial criteria
- Patient meets the standard Thrombocytopenia – Eltrombopag Products Prior Authorization Policy criteria
- AND BOTH of the following:
- • Patient has tried generic eltrombopag tablets [documentation required]; AND
- • Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) (e.g., dyes, fillers, preservatives) between the brand and the bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
same as duration noted in the standard Thrombocytopenia – Eltrombopag Products Prior Authorization Policy