CurrentCignaPolicy N/A

Thrombocytopenia - Eltrombopag Products Preferred Specialty Management Policy

Cigna coverage/program guidance that directs preferred use of generic eltrombopag tablets and exception criteria for non-preferred eltrombopag products for treatment of thrombocytopenia under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyThrombocytopenia - Eltrombopag Products Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeMaterial revision — preferred/non-preferred designations and exception criteria added

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization required for non-preferred eltrombopag products; try generic eltrombopag tablets first or document an exception per criteria.

SourceLink

POLICY UPDATE CHANGES

For Preferred Products, Promacta tablets and Promacta oral suspension were moved to Non-Preferred; generic eltrombopag tablets were added as a Preferred Product.

Alvaiz criteria changed to require trial of the Preferred Product (generic eltrombopag tablets) instead of Promacta.

Exception criteria were developed for Promacta tablets (brand), Promacta oral suspension (brand), and eltrombopag oral suspension (generic).

1Preferred product (generic eltrombopag tablets)

3Non-preferred products with exception criteria

04/30/2025most recent review date

06/11/2025

Policy Summary

PayerCigna

PolicyThrombocytopenia - Eltrombopag Products Preferred Specialty Management Policy

Policy CodePolicy N/A

Change TypeMaterial revision — preferred/non-preferred designations and exception criteria added

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization required for non-preferred eltrombopag products; try generic eltrombopag tablets first or document an exception per criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

selected revision date

Coverage Criteria

Non-Preferred Product Exception Criteria

Non-preferred products are covered as medically necessary only when the specified exception criteria are met; otherwise Preferred Product (generic eltrombopag tablets) is the encouraged option.

Alvaiz exception criteria: Approve for the duration noted in the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy if the patient meets BOTH of the following: (A) patient meets the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy criteria; AND (B) patient meets ONE of the following: (i) patient has tried generic eltrombopag tablets [documentation required]; OR (ii) patient is currently receiving Alvaiz.

If PA criteria met but exception (B) not met, approve generic eltrombopag tablets.

Promacta tablets (brand) exception criteria: Approve for the duration noted in the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy if the patient meets BOTH of the following: (A) patient meets the standard PA criteria; AND (B) patient meets BOTH of the following: (i) has tried generic eltrombopag tablets [documentation required]; AND (ii) cannot continue Preferred medication due to a formulation difference in inactive ingredient(s) (e.g., dyes, fillers, preservatives) that, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].

If PA criteria met but exception (B) not met, approve generic eltrombopag tablets.

Promacta oral suspension (brand) exception criteria: Approve for the duration noted in the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy if the patient meets BOTH of the following: (A) patient meets the standard PA criteria; AND (B) patient meets ONE of the following: (i) has tried generic eltrombopag tablets [documentation required]; OR (ii) cannot swallow or has difficulty swallowing tablets.

If PA criteria met but exception (B) not met, approve generic eltrombopag tablets.

Eltrombopag oral suspension (generic) exception criteria: Approve for the duration noted in the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy if the patient meets BOTH of the following: (A) patient meets the standard PA criteria; AND (B) patient meets ONE of the following: (i) has tried generic eltrombopag tablets [documentation required]; OR (ii) cannot swallow or has difficulty swallowing tablets.

If PA criteria met but exception (B) not met, approve generic eltrombopag tablets.

Any request for a non-preferred eltrombopag product that does not meet one of the specifically listed Non-Preferred Product Exception Criteria is not medically necessary and will not be approved.

Coding and Age Thresholds

Covered/Referenced Codesmixed

No codes listed

Age thresholds (documented in overview)

Alvaiz (eltrombopag choline) — ITP age thresholdFDA‑approved for pediatric and adult patients ≥6 years for persistent or chronic immune thrombocytopenia (ITP)

Promacta (eltrombopag olamine) — chronic ITP age thresholdChronic ITP indication available for patients ≥1 year of age

Promacta — severe aplastic anemia combination therapy age thresholdFirst‑line combination therapy with immunosuppressive agents available for patients ≥2 years of age

Provider Actions and Program Requirements

Denial Risk

Coding / claims denial risk

Claims submitted without a covered diagnosis or procedure code listed in the applicable coverage policy may be denied as not covered. When billing, providers must use the most appropriate codes as of the date of service. Reimbursement will not be provided for services billed for conditions or diagnoses that are not covered under this policy.

Claims lacking covered diagnosis or procedure codes per the applicable coverage policy are subject to denial.
Use the most appropriate codes as of the date of service; services billed for non-covered conditions will be denied.

Prior Authorization

Prior authorization and product preference

Prior authorization is required for Non-Preferred eltrombopag products. For Non-Preferred medications, the patient must meet the standard Thrombocytopenia - Eltrombopag Products Prior Authorization Policy criteria. If the patient meets those criteria but has not tried a Preferred Product, approval for a Preferred Product will be authorized.

Background

Eltrombopag agents (marketed as Promacta and Alvaiz, and available as generic formulations) are thrombopoietin receptor agonists used to treat thrombocytopenia, including immune thrombocytopenia (ITP), thrombocytopenia related to chronic hepatitis C, and severe aplastic anemia. Indications and pediatric age thresholds differ by product and formulation; the policy notes that Promacta is available in tablet and oral suspension formulations (with generic options) and Alvaiz is a choline salt tablet formulation.

Product Definitions

Alvaiz — key facts

Generic/Brand and formulationAlvaiz is eltrombopag choline available as tablets (9 mg, 18 mg, 36 mg, 54 mg)

FDA‑approved indicationsTreatment of thrombocytopenia in adults and pediatric patients ≥6 years with persistent or chronic ITP; thrombocytopenia in adults with chronic hepatitis C to allow interferon‑based therapy; severe aplastic anemia in adults after insufficient response to immunosuppressive therapy

Pediatric age thresholdApproved for pediatric patients aged ≥6 years for ITP

Promacta — key facts

Generic/Brand and formulationPromacta is eltrombopag olamine available as tablets (12.5 mg, 25 mg, 50 mg, 75 mg) and oral suspension (12.5 mg and 25 mg packets).

Indications — pediatric chronic ITP

Non-Preferred products require meeting the standard Prior Authorization Policy criteria.
If PA criteria are met but no Preferred Product trial has occurred, approval will be for a Preferred Product only.

Step Therapy

Step therapy requirement

Step therapy requires that prescribers try the Preferred Product (generic eltrombopag tablets) prior to approval of Non-Preferred eltrombopag products, except where specific exception criteria apply (e.g., inability to swallow tablets, currently receiving the non-preferred product, or documented formulation-related allergy/intolerance per the exception rules). If the patient meets the standard prior authorization criteria but has not met the step requirement, approval will be for the Preferred Product (generic eltrombopag tablets).

Preferred Product that must be tried first: generic eltrombopag tablets.
Exceptions: documented inability to swallow tablets (for suspensions), current use of the non-preferred product, or documented significant allergy/serious adverse reaction to formulation differences (per prescriber and with documentation).
If step requirement not met but standard PA criteria are met, authorize the Preferred Product.

Documentation Required

Documentation required

Documentation is required to support trials of generic eltrombopag tablets and any claimed exceptions. Acceptable documentation includes, but is not limited to, chart notes, prescription claims records, prescription receipts, and other supporting information. For exceptions based on formulation differences or inability to swallow, the prescriber must provide documentation explaining the clinical reason (e.g., allergy to inactive ingredients, swallowing impairment) as specified in the exception criteria.

Documentation types: chart notes, prescription claims records, prescription receipts, and other supporting records.
For formulation-difference exceptions: prescriber statement and supporting clinical documentation that the patient would have a significant allergy or serious adverse reaction to the preferred formulation.
For swallowability exceptions: documentation of inability or significant difficulty swallowing tablets.

Chronic ITP indication includes patients ≥1 year of age

Indications — severe aplastic anemiaApproved in combination with standard immunosuppressive therapy for first‑line treatment of severe aplastic anemia in patients ≥2 years of age