Promacta — Medical Mutual

Initial criteria

• According to prescriber, patient has poor graft function
• Patient age ≥ 18 years
• Patient platelet count < 50 x 10^9/L
• Medication is prescribed by or in consultation with a hematologist, oncologist, or stem cell transplant specialist physician

Reauthorization criteria

• According to the prescriber, the patient demonstrated a beneficial clinical response (e.g., increased platelet counts, maintenance of platelet counts, and/or decreased frequency of bleeding episodes)

Approval duration

3 months initial; 6 months reauth