CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization criteria for thrombopoietin receptor agonists (e.g., Nplate) — CVS Caremark prior authorization form

A CVS Caremark-administered prior authorization request form used by HMSA to obtain clinical information required to determine coverage for thrombopoietin receptor agonists (e.g., Nplate) and related agents; applies to prescribers and patients seeking drug coverage under the specialty prescription benefit.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization criteria for thrombopoietin receptor agonists (e.g., Nplate)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization to CVS Caremark via fax to 1-866-237-5512 with required clinical documentation including platelet counts and prior therapy history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19number of form questions

Platelet thresholdsplatelet decision points

Faxprior auth fax

Coverage criteria and decision logic

inv-01: Indication-specific coverage criteria

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Indication selection: Request must identify one of the covered indications: Immune thrombocytopenia (ITP); Hematopoietic syndrome of acute radiation syndrome; Myelodysplastic syndrome (MDS); Chemotherapy-induced thrombocytopenia (CIT); Other.

Form branches based on selected indication

ITP initial therapy: For ITP: documentation that the patient had inadequate response to or intolerance of prior therapy with corticosteroids, IV immunoglobulins, or splenectomy (Q6) AND submission of the lowest untransfused platelet count prior to initiation (Q7) with the following decision thresholds: <30,000/mcL → no further questions (not eligible for approval via form pathway); 30,000–50,000/mcL or >50,000/mcL → continue assessment (Q8). Also document symptomatic bleeding or bleeding risk factors if present (Q8).<30,000/mcL; 30,000–50,000/mcL; >50,000/mcL

Platelet counts and prior therapy required; attach labs and prior therapy documentation

CIT initial therapy: For CIT: platelet count remained <100,000/mcL for at least 3–4 weeks after last chemotherapy administration (Q9) OR chemotherapy administration has been delayed because of thrombocytopenia (Q10). Action required: attach laboratory documentation or chart notes with current platelet count.<100,000/mcL for 3–4 weeks

Labs required

ITP continuation therapy: For continuation in ITP: provide current platelet count (Q12) with the following branches: if <50,000/mcL → assess whether platelet count is sufficient to prevent clinically important bleeding (Q13); if insufficient, confirm the patient has received a maximal dose of the requested drug for at least 4 weeks (Q14) or that dosing will be adjusted to achieve a safe platelet count (Q15). If current platelet count is 50,000–200,000/mcL → no further questions; >400,000/mcL or unknown → no further questions per form logic.<50,000/mcL; 50,000–200,000/mcL; >200,000–<=400,000/mcL; >400,000/mcL

Document current labs; attach laboratory documentation

MDS continuation: For MDS: document evidence of benefit from therapy such as increased platelet counts, decreased bleeding events, or reduced need for platelet transfusions (Q16).

Clinical benefit must be documented; attach labs/chart notes

CIT continuation: For continuation in CIT: document that the requested drug is being used to maintain chemotherapy dose schedule and intensity (Q17) AND document clinical benefit (e.g., increased platelet counts, decreased bleeding events, reduced need for platelet transfusions) (Q18) and provide current platelet count (Q19).<100,000/mcL; >=100,000/mcL

Attach laboratory documentation or chart notes

The form requires documentation of specific platelet thresholds and prior therapy status for covered indications. For ITP, providers must submit prior therapy history (corticosteroids, IVIG, splenectomy) and the lowest untransfused platelet count prior to therapy, with explicit decision nodes for <30,000/mcL (no further questions) and other ranges (30,000–50,000/mcL, >50,000/mcL) (Questions 6–7). For CIT, the form asks for laboratory evidence that platelet counts remained <100,000/mcL for at least 3–4 weeks after chemotherapy or that chemotherapy was delayed due to thrombocytopenia (Questions 9–10). Requests that lack the required platelet counts or documentation of prior therapy failure/intolerance may not be able to meet the coverage criteria and therefore may be denied or receive an incomplete determination.

Key clinical thresholds and code-relevant values

Platelet count thresholds

Less than 30,000/mcL<30,000/mcL (30 x10^9/L) — triggers 'No Further Questions' for ITP initial therapy

30,000–50,000/mcL30,000 to 50,000/mcL (30–50 x10^9/L) — continues assessment for ITP (to Q8)

Greater than 50,000/mcL>50,000/mcL (>50 x10^9/L) — continues assessment for ITP (to Q8)

Less than 50,000/mcL (continuation)<50,000/mcL — for continuation assessment; may require Q13–Q15 if insufficient to prevent bleeding

50,000–200,000/mcL50,000 to 200,000/mcL — generally no further questions for continuation (Q12)

Greater than 200,000 to <=400,000/mcL>200,000/mcL to <=400,000/mcL — prompts assessment of dosing adjustment (Q15)

CIT threshold: <100,000/mcL<100,000/mcL (100 x10^9/L) sustained for at least 3–4 weeks post-chemotherapy — CIT initial criterion (Q9)

Submission, documentation, and prior authorization actions

Prior Authorization

Submit prior authorization request

Fax the completed prior authorization form and required clinical information to CVS Caremark at 1-866-237-5512. Include accurate diagnosis, prescriber information, and supporting documentation to allow timely review. For questions about the prior authorization, contact CVS Caremark at 1-808-254-4414. Approvals may be subject to dosing limits per FDA labeling, compendia, or evidence-based guidelines.

Fax: 1-866-237-5512
CVS Caremark phone: 1-808-254-4414
Include accurate diagnosis and prescriber details

Documentation Required

Prior therapy assessment required

Determinations require documentation of prior therapies. Document if the patient had an inadequate response or intolerance to prior treatments such as corticosteroids, IVIG (immunoglobulins), or splenectomy. Submit all previous drug therapies and responses as part of the authorization request.

Document inadequate response or intolerance to corticosteroids, immunoglobulins, or splenectomy
Attach records of prior drug therapies and clinical response

Documentation Required

Required clinical documentation

Attach laboratory documentation or chart notes showing current and historical platelet counts (including the lowest untransfused platelet count prior to initiation and current platelet count). Include notes or labs demonstrating clinical benefit or lack thereof when applicable (e.g., increase in platelet counts, decreased bleeding events, reduced transfusion need).

Lowest untransfused platelet count prior to therapy (e.g., <30,000/mcL)
Current platelet count with lab report or chart note
Documentation of clinical benefit or bleeding status

Denial Risk

Documentation-dependent determination

Final coverage decisions are documentation-dependent. If required clinical information (prior therapies, platelet counts, prescriber specialty/consultation notes, or benefit documentation) is missing or incomplete, the request may be denied or an incomplete determination may be issued. Maintain and provide supporting records upon request.

Incomplete or missing prior therapy documentation may result in denial
Missing platelet count labs may result in incomplete determination or denial
Ensure prescriber is hematologist/oncologist or include consultation notes when applicable

Indication definitions and criteria

Immune thrombocytopenia (ITP) — definition and treatment context

DefinitionImmune thrombocytopenia (ITP) identified as an indication for therapy on the form; requests must document diagnosis selection (Q5)

Prior therapy requirementForm asks whether patient had inadequate response or intolerance to corticosteroids, IVIG, or splenectomy (Q6); documentation of prior drug therapies is required

Baseline platelet requirementProvide lowest untransfused platelet count prior to initiation; specific decision nodes include <30,000/mcL (no further questions), 30,000–50,000/mcL or >50,000/mcL (continue assessment to symptomatic bleeding/risk Q8)

Bleeding assessmentForm requires documentation of symptomatic bleeding or bleeding risk factors (Q8) to support ITP treatment decisions

Continuation logicFor continuation, diagnosis must be confirmed (Q11) and current platelet count reported (Q12) with follow-up questions on sufficiency to prevent bleeding and prior maximal dosing (Q13–Q15)

Chemotherapy-induced thrombocytopenia (CIT) — criteria

DefinitionChemotherapy-induced thrombocytopenia (CIT) is identified on the form as an indication requiring assessment of platelet counts and chemotherapy impact (Q5, Q9)

Sustained platelet criterionPatient's platelet count must have remained less than 100,000/mcL for at least 3–4 weeks following last chemotherapy administration (Q9); attach laboratory documentation

Chemotherapy delayAlternatively, documentation that chemotherapy administration was delayed due to thrombocytopenia (Q10) satisfies initial CIT assessment

Continuation requirementsFor CIT continuation, form asks if the drug is used to maintain chemotherapy dose schedule and intensity (Q17) and requests evidence of benefit (Q18) plus current platelet count (Q19)

Background and scope

This prior authorization form is intended to collect the clinical details needed to determine coverage for thrombopoietin receptor agonists (for example, Nplate) across multiple indications including immune thrombocytopenia (ITP), chemotherapy-induced thrombocytopenia (CIT), myelodysplastic syndromes (MDS), and hematopoietic syndrome from acute radiation. The form captures the treating specialty, indication, prior therapies and responses, current and historical platelet counts, presence of symptomatic bleeding or bleeding risk factors, and whether therapy is being used to maintain chemotherapy dosing—information required to apply the indication-specific criteria and documentation-dependent coverage decisions.