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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONPromacta (eltrombopag) is an orally bioavailable, small molecule thrombopoietin (TPO) receptor agonist for oral administration. Eltombopag interacts with the transmembrane domain of the TPO receptor (also known as cMpl) leading to increased platelet production.
Promacta will be approved when the following are met:
i. The patient has a history of trial and failure of; or a documented intolerance, FDA labeled contraindication, or hypersensitivity to ONE of the following treatments: corticosteroids, immunoglobulins (IVIg or anti-D) OR
i. The patient’s platelet count is <75 x109/L AND the intent is to increase platelet counts sufficiently to initiate interferon therapy OR
a. The quantity requested is less than or equal to the program quantity limit OR
Length of Approval: 8 weeks Promacta for ITP. 12 weeks for Promacta for hepatitis C associated thrombocytopenia.
POLICY EXCEPTIONSPromacta prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
11/12/2014: Policy statement criteria regarding hepatitis C associated thrombocytopenia updated to change the platelet count from "<100 x109/L" to "<75 x109/L." Added criteria for Promacta for severe aplastic anemia to the policy statement.
08/14/2015: Code Reference section updated for ICD-10.
SOURCE(S)Promacta® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.