Promacta for oral suspension — United Healthcare

Initial criteria

• Diagnosis of severe aplastic anemia
• One of the following: (a) Used in combination with standard immunosuppressive therapy (e.g., Atgam [antithymocyte globulin equine], Thymoglobulin [antithymocyte globulin rabbit], cyclosporine) OR (b) History of failure, contraindication, or intolerance to at least one course of immunosuppressive therapy (e.g., Atgam, Thymoglobulin, cyclosporine)
• 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

6 months initial, 12 months reauthorization