Promacta — Medical Mutual

Initial criteria

• Patient has low platelet counts at baseline (pretreatment)
• Patient had tried at least one immunosuppressant therapy OR Patient will be using eltrombopag in combination with standard immunosuppressive therapy
• If request is for Promacta, patient age ≥ 2 years OR If request is for Alvaiz, patient age ≥ 18 years
• Medication is prescribed by or in consultation with a hematologist

Reauthorization criteria

• According to the prescriber, the patient demonstrates a beneficial clinical response (e.g., increases in platelet counts, reduction in red blood cell transfusions, hemoglobin increase, and/or absolute neutrophil count increase)

Approval duration

4 months initial; 6 months reauth