CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Doptelet (avatrombopag) coverage for thrombocytopenia

Defines prior authorization, coverage criteria, documentation, prescriber specialties, exclusions, and continuation rules for Doptelet (avatrombopag) for treatment of thrombocytopenia in chronic liver disease and chronic immune thrombocytopenia for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDoptelet (avatrombopag) coverage for thrombocytopenia

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with pretreatment platelet count for CLD or current platelet count for continuation and document prior therapy failure for ITP.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50x10^9/LCLD platelet threshold

30x10^9/LITP initiation threshold

30-50x10^9/LITP symptomatic range

30 daysCLD auth length

6 monthsITP auth length

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Coverage Criteria

Thrombocytopenia in chronic liver disease

Covered when ALL of the following are met for thrombocytopenia in chronic liver disease (CLD).

ALL of the following

Member has an untransfused platelet count of less than 50 x 10^9/L taken within 14 days of the request.
Member is scheduled to undergo a procedure.

Chronic immune thrombocytopenia (ITP) — Initial approval

Covered when ALL of the following are met for chronic immune thrombocytopenia (ITP) — initial approval.

ALL of the following

Inadequate response or intolerance to prior therapy (e.g., corticosteroids or immunoglobulins).
Untransfused platelet count at any point prior to initiation of the requested medication is < 30 x 10^9/L OR 30 to 50 x 10^9/L with symptomatic bleeding (e.g., significant mucous membrane bleeding, gastrointestinal bleeding or trauma) or risk factors for bleeding.

Continuation Therapy

Continuation Therapy — continuation rules by indication.

ALL of the following

Thrombocytopenia in chronic liver disease
- Continuation of therapy (use beyond the initial approval for the same procedure) is not approvable. All members (including new members) requesting authorization due to a newly scheduled procedure must meet all initial authorization criteria.
Chronic ITP
- Authorization of 12 months may be granted to members with current platelet count < 50 x 10^9/L for whom the current platelet count is sufficient to prevent clinically important bleeding.
- Authorization of 3 months may be granted to members with current platelet count < 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 weeks.

Coding & Thresholds

Platelet count thresholds

Chronic liver disease (CLD) initial thresholdUntransfused platelet count < 50 x 10^9/L measured within 14 days of the request; member must be scheduled to undergo a procedure

Chronic ITP initial thresholdsUntransfused platelet count prior to initiation < 30 x 10^9/L OR 30–50 x 10^9/L with symptomatic bleeding or risk factors for bleeding

CLD authorization lengthAuthorization of 30 days may be granted for treatment when CLD criteria are met

ITP initial authorization lengthAuthorization of 6 months may be granted for treatment of chronic ITP when initial criteria are met

ITP continuation thresholdsContinuation authorization varies by current platelet count: 12 months if current platelet count <50 x 10^9/L and sufficient to prevent clinically important bleeding; 3 months if <50 x 10^9/L and not sufficient with <4 weeks at maximal dose; 12 months for current platelet count 50–200 x 10^9/L; 12 months if current platelet count greater than sufficient to avoid clinically important bleeding

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Doptelet. Initial approvals: up to 30 days for thrombocytopenia in chronic liver disease when member has an untransfused platelet count <50 x 10^9/L taken within 14 days of the request and is scheduled to undergo a procedure; up to 6 months for chronic immune thrombocytopenia (ITP) when criteria are met.

Thrombocytopenia in chronic liver disease: initial approval up to 30 days
Chronic ITP: initial approval up to 6 months

Step Therapy

Prior Therapy Requirement

For chronic ITP, member must have inadequate response or intolerance to prior therapy (for example, corticosteroids or intravenous immunoglobulins) before Doptelet will be approved.

Document prior therapies tried and reason for discontinuation/intolerance

Definitions

Bleeding risk factors

Procedures with anticipated blood lossUndergoing a medical or dental procedure where blood loss is anticipated

Mandated anticoagulationMandated anticoagulation therapy

Relevant comorbiditiesComorbidities that increase bleeding risk (e.g., peptic ulcer disease, hypertension)

High‑trauma professions/lifestylesProfessions or activities that predispose to trauma (e.g., construction work, contact sports)

Symptomatic bleeding examplesSignificant mucous membrane bleeding, gastrointestinal bleeding, or bleeding after trauma (used to qualify 30–50 x 10^9/L ITP threshold)

Background

Avatrombopag (Doptelet) is a thrombopoietin receptor agonist indicated for two adult populations: (1) treatment of thrombocytopenia in patients with chronic liver disease (CLD) who are scheduled to undergo a procedure, and (2) treatment of thrombocytopenia in chronic immune thrombocytopenia (ITP) patients with an insufficient response to prior therapy. The policy uses pretreatment and current platelet counts to determine eligibility and links authorization duration to the specific indication and clinical response.