COVERED USES:

FDA-Approved Indications:

Treatment of thrombocytopenia in patients with chronic immune (idiopathic) thrombocytopenic purpura (ITP) who have had an insufficient response to corticosteroids, immuoglobulins, or splenectomy.

Promacta should only be used in patients with ITP whose degree of thrombocytopenia and clinical condition increase the risk for bleeding. Promacta should not be used in an attempt to normalize platelet counts.

All FDA approved indication not other wise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Prescribed by or in consultation with a hematologist.

REQUIRED MEDICAL INFORMATION:

Platelet Count.

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Must meet all of the following:

1. A diagnosis of Idiopathic Thrombocytopenic Purpura (ITP)
AND
2. Patient is at risk for bleeding with a platelet count of less than 30 x 10⁹/L
AND
3. Treatment by at least one of the following was ineffective or not tolerated:
   1. Systemic corticosteroids, OR
   2. Immune globulin, OR
   3. Splenectomy

Reauthorization will require submission of platelet counts and dose of 75mg per day or less.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial auth. will be approved for up to 3 months. Reauth. will be approved for up to 6 months.