CurrentMedical Mutual - OhioPolicy N/A

Doptelet (avatrombopag) — Coverage Criteria for Thrombocytopenia

Defines prior authorization and coverage criteria for Doptelet and Doptelet Sprinkle for thrombocytopenia related to chronic liver disease and chronic immune thrombocytopenia, including initial and continuation criteria and approval durations; applies to Medical Mutual - Ohio pharmacy benefit determinations.

Policy Summary

PayerMedical Mutual - Ohio

PolicyDoptelet (avatrombopag) — Coverage Criteria for Thrombocytopenia

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateN/A

Next Review DateOct 16, 2025

Key ActionObtain prior authorization; initial therapy must be prescribed by or in consultation with a specialist and response is required for reauthorization when specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2indications covered

60 mg x5<40 x10^9/L dosing

40 mg x540–50 x10^9/L dosing

7 daysCLD initial approval

3/6 moCITP approval

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Coverage Criteria

Thrombocytopenia in adults with chronic liver disease

Covered when ALL of the following are met for adults with chronic liver disease scheduled for a procedure.

CLD procedural criteria: A. ≥ 18 years of age; AND B. Has been diagnosed with chronic liver disease; AND C. Has thrombocytopenia with platelet count < 50,000 mcL; AND D. Is scheduled to undergo a procedure within 10 to 13 days after starting Doptelet therapyplatelet < 50,000 mcL

Dosing recommended 10–13 days before procedure; perform procedure 5–8 days after last dose.

Chronic Immune Thrombocytopenia - initial therapy (adult)

Covered when ALL of the following are met for adult initial therapy for chronic immune thrombocytopenia.

CITP initial (adult): A. The patient has been diagnosed with chronic immune thrombocytopenia for at least 12 months; AND B. The patient has previously tried corticosteroids or IVIG, unless contraindicated; AND C. The patient's platelet count is < 50,000/mcL prior to use of any thrombopoietin receptor agonist; AND D. Doptelet will NOT be used in combination with another therapy for chronic immune thrombocytopenia; AND E. Doptelet is prescribed by or in consultation with a hematologistplatelet < 50,000/mcL

Prescriber specialty requirement: hematologist.

Chronic Immune Thrombocytopenia - continuation of therapy (adult)

Covered when ALL of the following are met for continuation of therapy in chronic immune thrombocytopenia (adult).

CITP continuation (adult): A. The patient has had a platelet response after 4 weeks of Doptelet therapy as evidenced by platelet count greater than 50,000/mcL; AND B. The patient is not using Doptelet in combination with another therapy for chronic immune thrombocytopenia (for example: Promacta, Nplate); AND C. Doptelet is prescribed by or in consultation with a hematologistplatelet > 50,000/mcL at 4 weeks

Example prohibited combination therapies: Promacta, Nplate.

Chronic Immune Thrombocytopenia, Chronic or Persistent - initial therapy (1-6 years)

Covered when ALL of the following are met for Doptelet Sprinkle in children 1–6 years (chronic or persistent ITP) - initial therapy.

Pediatric CITP initial (1-6 yrs): A. Patient is 1-6 years of age; AND B. The patient has been diagnosed with chronic immune thrombocytopenia for at least 12 months; AND C. The patient has previously tried corticosteroids or IVIG, unless contraindicated; AND D. The patient's platelet count is < 50,000/mcL prior to use of any thrombopoietin receptor agonist; AND E. Doptelet will NOT be used in combination with another therapy for chronic immune thrombocytopenia; AND F. Doptelet is prescribed by or in consultation with a hematologistplatelet < 50,000/mcL

Pediatric prescriber specialty: hematologist.

Chronic Immune Thrombocytopenia - continuation (1-6 years)

Covered when ALL of the following are met for continuation of Doptelet Sprinkle in children 1–6 years.

Pediatric CITP continuation (1-6 yrs): A. Patient is 1-6 years of age; AND B. The patient has had a platelet response after 4 weeks of Doptelet therapy as evidenced by platelet count greater than 50,000/mcL; AND C. The patient is not using Doptelet in combination with another therapy for chronic immune thrombocytopenia (for example: Promacta, Nplate); AND D. Doptelet is prescribed by or in consultation with a hematologistplatelet > 50,000/mcL at 4 weeks

Example prohibited combination therapies: Promacta, Nplate.

Coverage is not recommended for circumstances that are not explicitly listed in the policy’s Recommended Authorization Criteria. The policy further clarifies that the list of conditions not recommended for approval is not exhaustive and will be updated as new published data become available.

Requests for uses that are not described in this policy will be evaluated on a case-by-case basis; however, such requests are generally not recommended for approval unless supporting evidence demonstrates efficacy and safety for the proposed use.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for pharmacy benefit coverage of Doptelet. Initial approval requires the medication be prescribed by or in consultation with an appropriate specialist (e.g., hematologist) due to the specialized evaluation and monitoring required.

Initial approval requires prescription by or in consultation with a specialist.

Step Therapy

Step Therapy Requirement

For chronic immune thrombocytopenia initial therapy, the patient must have previously tried corticosteroids or IVIG unless these therapies are contraindicated.

Applies to initial therapy for chronic or persistent immune thrombocytopenia (including pediatric 1-6 years criteria where applicable).

Dosing & Platelet Thresholds

Platelet thresholds and dosing for CLD procedural indication

Indication platelet thresholdPlatelet count < 50,000 mcL required for CLD procedural indication

Dosing for platelet < 40 x10^9/L60 mg orally once daily for 5 days

Dosing for platelet 40 to <50 x10^9/L40 mg orally once daily for 5 days

Timing of therapy relative to procedureBegin Doptelet 10–13 days before scheduled procedure; perform procedure 5–8 days after last dose

Definitions

Doptelet use and timing for CLD procedural thrombocytopenia

Indication and thresholdDoptelet indicated for thrombocytopenia in adults with chronic liver disease scheduled for a procedure when platelet count < 50,000 mcL

Dosing regimen by platelet count60 mg daily x5 days if platelet < 40 x10^9/L; 40 mg daily x5 days if platelet > 40 to <50 x10^9/L

Treatment timingStart therapy 10–13 days before the procedure; schedule procedure 5–8 days after last dose

Chronic Immune Thrombocytopenia (adult) definitions and prerequisites

Definition of chronic ITP (adult)Diagnosis of chronic immune thrombocytopenia for at least 12 months (≥ 12 months)

Prior therapy requirementPatient must have previously tried corticosteroids or IVIG unless these are contraindicated

Background

Doptelet (avatrombopag) is a thrombopoietin receptor agonist indicated to treat thrombocytopenia in adults with chronic liver disease who are scheduled to undergo a procedure and in adults with chronic immune thrombocytopenia with insufficient response to prior therapies. For the chronic liver disease procedural indication, Doptelet dosing is started approximately 10–13 days before the procedure with the procedure performed 5–8 days after the last dose; the aim is to raise platelet counts to acceptable thresholds to reduce the need for platelet transfusion or rescue procedures.