Subject: Specialty Quantity Limit Doptelet 2583-H P2021

Drug

DOPTELET  (avatrombopag)

Policy:

I.     PROGRAM DESCRIPTION
       The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended
       dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be
       reviewed on a case-by-case basis upon request.


II.   COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Doptelet (avatrombopag) 20 mg tablets, 1 carton of one blister card with 10 tablets	1 carton per 5 days	Thrombocytopenia in chronic liver disease:      1. Platelet count less than 40x109/L: 60 mg (3 tablets) once         daily for 5 consecutive days with food.      2. Platelet count 40x109/L to less than 50x109/L: 40 mg (2         tablets) once daily for 5 consecutive days with food. Chronic immune thrombocytopenia: initiate at 20 mg (1 tablet) once daily with food. Adjust to maintain platelet count greater than or equal to 50 x 109/L. Do not exceed a daily dose of 40 mg (2 tablets).
Doptelet (avatrombopag) 20 mg tablets, 1 carton of one blister card with 15 tablets	1 carton per 5 days
Doptelet (avatrombopag) 20 mg tablets,1 carton of two blister cards with 15 tablets (30 tablets total)	2 cartons per 30 days

Place of Service:

Outpatient

The above policy is based on the following references:

1. Doptelet [package insert]. Durham, NC: AkaRx, Inc.; October 2020.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 14, 2021