Subject: Specialty Quantity Limit Promacta 1757-H P2021
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
|
|
Promacta
(eltrombopag) 12.5
mg tablets
|
30 per 30 days
|
Persistent or chronic ITP: initiate at 50 mg once daily for
most adult and pediatric patients 6 years and older and
at 25 mg once daily for pediatric patients aged 1 to 5
years. Dose reductions are needed for patients of Asian
ancestry or those with hepatic impairment. Adjust to
maintain platelet count greater than or equal to 50 x
109/L. Do not exceed 75 mg per day.
Chronic Hep C-associated thrombocytopenia: initiate at
25 mg once daily. Adjust to achieve target platelet count
required to initiate antiviral therapy. Do not exceed a
daily dose of 100 mg.
First-line severe aplastic anemia: Initiate once daily at
2.5 mg/kg (in pediatric patients aged 2 to 5 years old),
75 mg (pediatric patients aged 6 to 11 years old), or 150
mg for patients aged 12 years and older concurrently
with standard immunosuppressive therapy. Reduce initial
dose in patients of Asian ancestry or those with hepatic
impairment. Modify dosage for toxicity or elevated
platelet counts.
Refractory severe aplastic anemia: initiate at 50 mg once
daily for most patients. Reduce initial dose in patients
with hepatic impairment or patients of Asian ancestry.
Adjust to maintain platelet count greater than or equal
to 50 x 109/L. Do not exceed 150 mg per day.
|
|
Promacta
(eltrombopag) 25 mg tablets
|
|
Promacta
(eltrombopag) 12.5
mg oral suspension
packets
|
120 packets per
30 days
|
|
Promacta
(eltrombopag) 25 mg oral suspension
packets
|
180 packets per
30 days
|
|
Promacta
(eltrombopag) 50 mg tablets
|
60 per 30 days
|
|
Promacta
(eltrombopag) 75 mg
tablets
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Promacta [package insert]. Research Triangle Park, NC: GlaxoSmithKline; February 2021.
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 17, 2021
