CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 1083-17

Eltrombopag (Promacta, Alvaiz) prior authorization criteria

Prior authorization/notification policy governing coverage of eltrombopag (Promacta and Alvaiz) for indications including chronic immune thrombocytopenia (ITP), chronic hepatitis C-associated thrombocytopenia to allow interferon-based therapy, and severe aplastic anemia; notes Promacta tablet formulation is excluded from coverage for the majority of benefits.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEltrombopag (Promacta, Alvaiz) prior authorization criteria

Policy CodePolicy 2025 P 1083-17

Change TypeAdded product; formulation exclusion; annual review

Effective DateNov 1, 2025

Next Review Date

Key ActionPrior authorization/notification required for Promacta and Alvaiz; approvals issued for 12 months for covered indications.

POLICY UPDATE CHANGES

Added Alvaiz to the program.

Added statement that the Promacta tablet formulation is excluded from coverage for the majority of benefits.

Annual review with no change to coverage criteria; updated references.

3Covered Indications (ITP, Hep C thrombocytopenia, Severe aplastic anemia)

1Excluded formulation (Promacta tablet)

12 monthsAuthorization duration

Coverage Summary

Prior authorization/notification policy governing coverage of eltrombopag (Promacta and Alvaiz) for chronic immune thrombocytopenia (ITP), chronic hepatitis C-associated thrombocytopenia to permit interferon-based therapy, and severe aplastic anemia; Promacta tablet formulation is excluded from coverage for the majority of benefits. Metadata: coverage stance = covered_with_criteria; policy number = 2025 P 1083-17.

Initial Therapy Criteria

Initial Authorization for Chronic Immune Thrombocytopenia (ITP)

Promacta or Alvaiz will be approved when ALL of the following are met:

ALL of the following

Diagnosis of chronic immune thrombocytopenia (ITP)
Patient has had an insufficient response to a previous treatment (e.g., corticosteroids, immunoglobulins, thrombopoietin receptor agonists, splenectomy)

Initial Authorization for Chronic Hepatitis C‑Associated Thrombocytopenia

Promacta or Alvaiz will be approved when ALL of the following are met:

ALL of the following

Diagnosis of chronic hepatitis C-associated thrombocytopenia
ONE of
- Planning to initiate and maintain interferon-based treatment
- Currently receiving interferon-based treatment

Initial Authorization for Severe Aplastic Anemia

Promacta or Alvaiz will be approved when ALL of the following are met:

ALL of the following

Diagnosis of severe aplastic anemia
ONE of
- Used in combination with standard immunosuppressive therapy (e.g., Atgam [antithymocyte globulin equine], Thymoglobulin [antithymocyte globulin rabbit], cyclosporine)
- History of failure, contraindication, or intolerance to at least one course of immunosuppressive therapy (e.g., Atgam, Thymoglobulin, cyclosporine)

Continuation / Reauthorization Criteria

Reauthorization for Chronic Immune Thrombocytopenia (ITP)

Promacta or Alvaiz will be reapproved when ALL of the following are met:

ALL of the following

Documentation of positive clinical response to Promacta or Alvaiz therapy

Reauthorization for Chronic Hepatitis C‑Associated Thrombocytopenia

Promacta or Alvaiz will be reapproved when ALL of the following are met:

ALL of the following

Documentation of positive clinical response to Promacta or Alvaiz therapy
Patient is currently on antiviral interferon therapy for treatment of chronic hepatitis C

Reauthorization for Severe Aplastic Anemia

Promacta or Alvaiz will be reapproved when ALL of the following are met:

ALL of the following

Documentation of positive clinical response to Promacta or Alvaiz therapy

Unproven / Exclusions

Promacta tablet formulation is excluded from coverage for the majority of benefits; coverage applies to approved formulations per program. This formulation exclusion was added to the program in 8/2024. Providers should follow the program billing rules and prior authorization processes for Promacta and Alvaiz when submitting claims.

Excluded formulationmixedNot Covered

Promacta tablet formulation

Excluded from coverage for the majority of benefits

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization/notification is required for Promacta and Alvaiz. Approvals are issued for 12 months for covered indications.

Documentation Required

Document response for reauthorization

Documentation of a positive clinical response to Promacta or Alvaiz therapy is required for reauthorization. Authorizations are issued for 12 months.

Billing Rule

Formulation exclusion

The Promacta tablet formulation is excluded from coverage for the majority of benefits. Coverage applies only to approved formulations per the program (for example, other approved formulations such as oral suspension or as applicable).

Prior Authorization

Hepatitis C indication requires interferon therapy linkage

For the chronic hepatitis C–associated thrombocytopenia indication, prior authorization requires that the member is planning to initiate and maintain interferon-based treatment or is currently receiving interferon-based treatment.

Background

Eltrombopag (Promacta and Alvaiz) are thrombopoietin receptor agonists indicated for thrombocytopenia in adult and pediatric patients with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy; for thrombocytopenia in patients with chronic hepatitis C to allow initiation and maintenance of interferon-based therapy; and for patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy. Promacta is also approved in combination with standard immunosuppressive therapy for first-line treatment of severe aplastic anemia in patients 2 years and older.

Revision History

2024-06material_addition

Added Alvaiz to the program.

2024-08material_addition

Added statement that the Promacta tablet formulation is excluded from coverage for the majority of benefits.

2025-08annual_reviewLatest

Annual review with no change to coverage criteria; updated references.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEltrombopag (Promacta, Alvaiz) prior authorization criteria

Policy CodePolicy 2025 P 1083-17

Change TypeAdded product; formulation exclusion; annual review

Effective DateNov 1, 2025

Next Review Date

Key ActionPrior authorization/notification required for Promacta and Alvaiz; approvals issued for 12 months for covered indications.

On This Page

OpenPayer

Eltrombopag (Promacta, Alvaiz) prior authorization criteria

Coverage Summary

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Unproven / Exclusions

Provider Actions

Clinical Evidence & References

Background

Revision History