eltrombopag for oral suspension — United Healthcare

Initial criteria

• Diagnosis of chronic hepatitis C-associated thrombocytopenia
• One of the following: (a) Planning to initiate and maintain interferon-based treatment OR (b) Currently receiving interferon-based treatment
• One of the following: (a) Patient is unable to ingest a solid dosage form (e.g. oral tablet or capsule) due to age, oral/motor difficulties, or dysphagia OR (b) Patient utilizes a feeding tube for medication administration

Reauthorization criteria

• Documentation of positive clinical response to Promacta oral suspension
• Patient is currently on antiviral interferon therapy for treatment of chronic hepatitis C

Approval duration

12 months