CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Doptelet (avatrombopag) coverage for thrombocytopenia

Defines coverage, prior authorization documentation, prescriber specialty requirements, exclusions, and initial/continuation approval criteria for Doptelet (avatrombopag) for thrombocytopenia in chronic liver disease (CLD) and chronic immune thrombocytopenia (ITP).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDoptelet (avatrombopag) coverage for thrombocytopenia

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit pretreatment platelet counts for CLD and initial ITP requests and current platelet counts for ITP continuations when requesting prior authorization.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Covered Indications

1Exclusions listed

3ITP continuation pathways

Coverage Summary & Indications

Doptelet (avatrombopag) is a thrombopoietin receptor agonist indicated for: (1) treatment of thrombocytopenia in adult patients with chronic liver disease (CLD) who are scheduled to undergo a procedure, and (2) treatment of thrombocytopenia in adult patients with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment. Coverage is covered with criteria for these FDA‑approved indications when all approval criteria are met. All other indications are considered experimental/investigational and not medically necessary.

FDA-Approved Indications (covered when all approval criteria are met)

Doptelet is covered for the following FDA-approved indications when all criteria below are met and no exclusions apply:

Indication

Treatment of thrombocytopenia in patients with chronic liver disease
- CLD initial criteria
  - Untransfused platelet count: Member has an untransfused platelet count of less than 50 x 10^9/L taken within 14 days of the request<50 x 10^9/L within 14 days
  - Procedure scheduled: Member is scheduled to undergo a procedure
Treatment of thrombocytopenia in chronic immune thrombocytopenia (ITP)
- Prior therapy failure: Inadequate response or intolerance to prior therapy (e.g., corticosteroids or immunoglobulins)
- Baseline platelet requirement
  - Baseline <30: Untransfused platelet count at any point prior to initiation is less than 30 x 10^9/L<30 x 10^9/L
  - Baseline 30-50 with bleeding: Untransfused platelet count 30 x 10^9/L to 50 x 10^9/L with symptomatic bleeding (e.g., significant mucous membrane bleeding, gastrointestinal bleeding or trauma) or risk factors for bleeding30-50 x 10^9/L with symptomatic bleeding or risk factors

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Initial Authorization Criteria

Documentation required to initiate prior authorization

Submission of the following information is necessary:

CLD pretreatment platelet: For CLD indication: pretreatment platelet count for initial requestspretreatment platelet count
ITP initial pretreatment platelet: For chronic ITP initial requests: pretreatment platelet countpretreatment platelet count
ITP continuation current platelet: For chronic ITP continuation requests: current platelet countcurrent platelet count

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Prior Authorization

Prior authorization required

Prior authorization requires submission of pretreatment (untransfused) platelet counts: for chronic liver disease (CLD) initial requests, an untransfused platelet count of less than 50 x 10^9/L measured within 14 days of the request; for chronic immune thrombocytopenia (ITP) initial requests, an untransfused platelet count prior to initiation (see ITP baseline thresholds).

CLD initial: untransfused platelet count < 50 x 10^9/L within 14 days of request
ITP initial: untransfused platelet count prior to initiation (see ITP thresholds)

Documentation Required

Document prior therapy failure for ITP

For ITP initial requests, document inadequate response or intolerance to prior therapy (for example, corticosteroids or immunoglobulins) as part of the prior authorization submission.

Continuation Therapy Criteria (ITP & CLD)

Continuation Criteria

Conditions under which continuation of therapy may be authorized:

CLD continuation: Thrombocytopenia in CLD: continuation beyond initial approval for the same procedure is not approvable; all members requesting authorization for a newly scheduled procedure must meet initial authorization criteriano continuation for same procedure
Chronic ITP continuations
- ITP authorization durations and platelet bands
  - 3-month authorization: Authorization of 3 months: current platelet count less than 50 x 10^9/L for whom the platelet count is not sufficient to prevent clinically important bleeding and who have not received a maximal Doptelet dose for at least 4 weekscurrent <50 x 10^9/L; not sufficient to prevent bleeding; not on max dose for ≥4 weeks
  - 12-month current <50 sufficient: Authorization of 12 months: current platelet count less than 50 x 10^9/L for whom the current platelet count is sufficient to prevent clinically important bleedingcurrent <50 x 10^9/L; sufficient to prevent bleeding
  - 12-month 50-200: Authorization of 12 months: current platelet count of 50 x 10^9/L to 200 x 10^9/L50-200 x 10^9/L
  - 12-month >200-<=400 with adjustment: Authorization of 12 months: current platelet count >200 x 10^9/L to <=400 x 10^9/L when Doptelet dosing will be adjusted to achieve a platelet count sufficient to avoid clinically important bleeding>200 to <=400 x 10^9/L with dose adjustment

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For the CLD indication, continuation of therapy beyond the initial approval for the same procedure is not approvable. Any member (including a new member) requesting authorization for a newly scheduled procedure must meet all initial authorization criteria. For chronic ITP, separate continuation rules and authorization durations apply based on current platelet counts and response as specified in the criteria.

Not Covered / Exclusions

Exclusions

Doptelet will not be covered when the following apply:

Concomitant TPO-RA: Concomitant use of Doptelet with other thrombopoietin receptor agonists (e.g., Mulpleta, Promacta, Nplate)no concomitant TPO-RAs
Concomitant SYK inhibitors: Concomitant use of Doptelet with spleen tyrosine kinase inhibitors (e.g., Tavalisse)no concomitant SYK inhibitors

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Denial Risk

Concomitant therapy exclusion

Claims will not be covered when Doptelet is used concomitantly with other thrombopoietin receptor agonists or with spleen tyrosine kinase inhibitors.

Mulpleta
Promacta
Nplate
Tavalisse

Provider Actions & Prescribing Requirements

Prescriber specialty requirements

Prescriber requirements by indication:

CLD prescriber: For thrombocytopenia in chronic liver disease: must be prescribed by or in consultation with a hematologist, hepatologist or gastroenterologistrequired specialty: hematologist, hepatologist, or gastroenterologist
ITP prescriber: For chronic ITP: must be prescribed by or in consultation with a hematologistrequired specialty: hematologist

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Documentation Required

Prescriber specialty confirmation

Ensure the prescription is written by or in consultation with the required specialist: for CLD indications, a hematologist, hepatologist, or gastroenterologist; for chronic ITP, a hematologist.

Definitions & Background

Untransfused platelet count: platelet count measured without a recent platelet transfusion (documented as untransfused). This is required as the pretreatment or baseline platelet measure for authorization decisions.

Clinically important bleeding: significant mucous membrane bleeding, gastrointestinal bleeding, trauma‑related bleeding, or presence of bleeding risk factors (for example, anticipated procedural blood loss, comorbidities such as peptic ulcer disease, mandated anticoagulation, or activities/occupations that predispose to trauma).

Context: Doptelet is indicated for thrombocytopenia in adults with CLD scheduled for a procedure and for chronic ITP with prior insufficient response; other uses are investigational and not medically necessary.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDoptelet (avatrombopag) coverage for thrombocytopenia

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit pretreatment platelet counts for CLD and initial ITP requests and current platelet counts for ITP continuations when requesting prior authorization.

On This Page

OpenPayer

Doptelet (avatrombopag) coverage for thrombocytopenia

Coverage Summary & Indications

Initial Authorization Criteria

Continuation Therapy Criteria (ITP & CLD)

Not Covered / Exclusions

Provider Actions & Prescribing Requirements

Applicable Codes

Clinical Evidence & References

Definitions & Background

Revision History