Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Initial Criteria
Romiplostim (Nplate) may be considered medically necessary when ALL of the following criteria are met:
- The individual has a diagnosis of immune (idiopathic) thrombocytopenia (ITP); and
- ONE of the following:
- The individual is between the ages of 1 and 17 years old AND the diagnosis has lasted for at least 6 months; or
- The individual is 18 years old or over; and
- ONE of the following:
- The individual has a platelet count ≤ 30 X 109/L; or
- The individual has a platelet count > 30 X 109/L but < 50 x 109/L AND has symptomatic bleeding and/or an increased risk for bleeding; and
- ONE of the following:
- The individual has had an insufficient response to a splenectomy; or
- The individual has tried and had an inadequate response to corticosteroids or immunoglobulins (IVIg or anti-D); or
- The individual has a documented intolerance, FDA labeled contraindication, or hypersensitivity to corticosteroids; and
- ONE of the following:
- The individual is NOT being treated with another thrombopoietin receptor agonist (e.g., Doptelet, Mulpleta, Promacta, Tavalisse); or
- The individual is currently being treated with another thrombopoietin receptor agonist AND will discontinue prior to initiating romiplostim (Nplate); and
- The prescriber has provided the individual's weight.
Initial Length of Approval: 4 months
Renewal Criteria
Romiplostim (Nplate) maybe renewed when the following are met:
- The individual has been previously approved for romiplostim (Nplate) through the Blue Cross Blue Shield of North Dakota approval process; and
- The individual has a diagnosis of immune (idiopathic) thrombocytopenia (ITP) AND ONE of the following:
- The individual’s platelet count is ≥50 x 109/L; or
- The individual’s platelet count has increased sufficiently to avoid clinically important bleeding; and
- The individual will NOT receive the requested agent in combination with another thrombopoietin receptor agonist (e.g., Doptelet, Mulpleta, Promacta, Tavalisse); and
- The prescriber has provided the individual’s weight.
Renewal Length of Approval: 12 months
Romiplostim (Nplate) for any other indication not listed within this policy will be considered experimental/investigational and, therefore, not-covered. Scientific evidence does not support its efficacy or safety for any other indications.
Procedure Codes