Thrombocytopenia - Mulpleta Prior Authorization Policy
Defines Cigna prior authorization requirements for Mulpleta (lusutrombopag) for adults with thrombocytopenia related to chronic liver disease undergoing a procedure; applies to prescription benefit plans administered by Cigna companies.
No material clinical or coverage changes in this revision.
Coverage Criteria for Mulpleta (lusutrombopag)
Initial FDA-approved use
Covered when ALL of the following are met
FDA-Approved Indication: Thrombocytopenia in chronic liver disease
- Patient is >= 18 years of age.
- Patient has a current platelet count < 50 x 10^9/L (< 50,000/mcL).
- Patient is scheduled to undergo a procedure within 8 to 14 days after starting Mulpleta therapy.
Mulpleta (lusutrombopag) is not medically necessary for any uses other than the FDA‑approved indication. This includes, but is not limited to, use for chronic immune thrombocytopenia. The policy excludes other unproven or non‑approved indications and will be updated as new published data become available.
Use of Mulpleta for chronic immune thrombocytopenia is specifically considered not medically necessary. The policy cites a lack of available data for persistent and chronic immune thrombocytopenia and notes that multiple other FDA‑approved agents with established efficacy and safety are recommended in standard guidelines for this condition.
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