Alvaiz — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• Patient has low- to intermediate-risk myelodysplastic syndrome
• Patient has platelet count < 30 x 10^9/L OR platelet count < 50 x 10^9/L AND at increased risk for bleeding
• Medication is prescribed by or in consultation with a hematologist or oncologist

Reauthorization criteria

• According to the prescriber, the patient demonstrates a beneficial clinical response (e.g., increased platelet counts, maintenance of platelet counts, and/or decreased frequency of bleeding episodes)
• Patient remains at risk for bleeding complications

Approval duration

3 months initial; 6 months reauth