Tavalisse — Medical Mutual

Initial criteria

• Patient age ≥ 18 years; AND
• Prescribed by or in consultation with a hematologist; AND
• Patient has tried corticosteroids or IVIG, unless contraindicated; AND
• Patient has tried Doptelet, or Doptelet is contraindicated; AND
• Patient meets one of the following: (i) platelet count < 30 × 10^9/L (< 30,000/µL); OR (ii) platelet count < 50 × 10^9/L (< 50,000/µL) AND according to prescriber patient is at increased risk of bleeding (e.g., upcoming medical/dental procedure, peptic ulcer disease, hypertension, anticoagulation therapy, profession/lifestyle predisposing to trauma)

Reauthorization criteria

• According to prescriber the patient demonstrates a beneficial clinical response (e.g., increased platelet counts); AND
• Patient remains at risk for bleeding complications

Approval duration

initial 90 days; reauth 365 days