eltrombopag for oral suspension — United Healthcare

Initial criteria

• Diagnosis of chronic immune thrombocytopenia (ITP)
• Patient has had an insufficient response to a previous treatment (e.g., corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy)
• 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 for oral suspension therapy

Approval duration

12 months