Subject: Specialty Quantity Limit Doptelet 2583-H P2025a

Drug

DOPTELET  (avatrombopag)

Policy:

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.

Covered Quantities

Medication	Standard Limit
Doptelet (avatrombopag) 20 mg tablets, 1 carton of one blister card with 10 tablets	1 carton per 5 days
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
Doptelet (avatrombopag) Sprinkle 10 mg capsules	60 capsules per 30 days

FDA-Recommended dosing

Thrombocytopenia in Chronic Liver Disease Scheduled to Undergo a Procedure

Platelet count less than 40x10⁹/L

60 mg (3 tablets) once daily for 5 consecutive days.

Platelet count 40x10⁹/L to less than 50x10⁹/L

40 mg (2 tablets) once daily for 5 consecutive days.

Immune Thrombocytopenia (ITP)

Adults with chronic ITP and pediatrics 6 years of age or older with persistent or chronic ITP: Initiate at 20 mg (1 tablet) once daily. Adjust to maintain platelet count greater than or equal to 50x10⁹/L. Do not exceed a daily dose of 40 mg (2 tablets).

Pediatric patients 1 year to less than 6 years of age with persistent or chronic ITP: Initiate at 10 mg (content of 1 capsule) orally once daily with food. Adjust to maintain platelet count greater than or equal to 50x10⁹/L. Do not exceed a daily dose of 20 mg (content of 2 capsules).

Place of Service:

Outpatient

The above policy is based on the following references:

1. Doptelet [package insert]. Durham, NC: AkaRx, Inc.; July 2025.

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.

November 01, 2025