Promacta — Medical Mutual

Initial criteria

• Patient has a platelet count < 30 x 10^9/L (< 30,000/mcL) OR platelet count < 50 x 10^9/L (< 50,000/mcL) AND at increased risk for bleeding
• Patient has tried at least one other therapy (e.g., systemic corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, Nplate, Tavalisse, Doptelet, rituximab) OR Patient has undergone splenectomy
• If request is for Promacta, patient age ≥ 1 year OR If request is for Alvaiz, patient age ≥ 6 years
• Patient < 18 years of age OR Patient has tried Doptelet or Doptelet is contraindicated
• 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., increased platelet counts, maintenance of platelet counts, and/or decreased frequency of bleeding episodes)
• Patient remains at risk for bleeding complications
• Patient < 18 years of age OR Patient has tried Doptelet or Doptelet is contraindicated

Approval duration

3 months initial; 6 months reauth