Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Pennsylvania / Aetna Better Health Kids at 1-877-309-8077. When conditions are met, we will authorize the coverage of Promacta (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Promacta (eltrombopag) Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. Question Circle es or o 1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If no, skip to question 22.] 2. Does the member have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)? [If no, skip to question 10.] 3. Does the member meet any of the following criteria for discontinuation of Promacta: A) member has experienced excessive platelet count responses with Promacta treatment, or B) important liver test abnormalities necessitate Reference umber: C14499-A / Effective Date: 12/03/2018 1
discontinuation of Promacta? Circle es or o 4. Does the member have a platelet count of at least 50,000/mm3 and less than 200,000/mm3? OTE: Lab results for platelets must be submitted with request. Requests 5. Does the member have a platelet count of less than 50,000/mm3? OTE: Lab results for platelets must be submitted with request. Requests [If no, skip to question 8.] 6. Has the member received 4 weeks of treatment with Promacta dosed at 75 mg daily? 7. Is the dose of Promacta being increased to 75 mg? [o further questions.] 8. Does the member have a platelet count of at least 200,000/mm3 and less than 400,000/mm3? OTE: Lab results for platelets must be submitted with request. Requests 9. Will the dose of Promacta be decreased? [o further questions.] 10.Does the member have a diagnosis of aplastic anemia? [If no, skip to question 16.] 11. Is the following true for the member: member has a platelet count of more than 400,000/mm3 after 2 weeks of the lowest dose of Promacta? 12.Does the member have a platelet count of at least 50,000/mm3? Reference umber: C14499-A / Effective Date: 12/03/2018 2
Circle es or o OTE: Lab results for platelets must be submitted with request. Requests 13.Has the member received 16 weeks of treatment with Promacta? [If no, skip to question 15.] 14.Has the member had a response to treatment indicated by at least OE of the following: A) platelet count increase by at least 20,000/mm3 above baseline; B) stable platelet count without requiring transfusions for at least 8 weeks; C) hemoglobin increase by more than 1.5 g/dl above baseline; D) reduction in red blood cell (RBC) transfusions by at least 4 units for 8 consecutive weeks; E) doubling of baseline absolute neutrophil count (AC) or an increase in AC to above 500? OTE: Lab results to support a response to Promacta must be submitted with request. Requests [o further questions.] 15.Is the dose of Promacta being increased? OTE: The dose should be increased by 50 mg every 2 weeks until platelets are at least 50,000/mm3 or to a maximum of 150 mg. [o further questions.] 16.Does the member have a diagnosis of Hepatitis C with thrombocytopenia? 17.Does the member meet any of the following criteria for discontinuation of Promacta: A) platelet count of more than 400,000/mm3, B) excessive platelet count response, or C) important liver test abnormalities? 18.Does the member have a platelet count of at least 90,000/mm3? OTE: Lab results for platelets must be submitted with request. Requests [If no, skip to question 20.] 19.Has a separate prior authorization been submitted to start or reinitiate antiviral treatment with pegylated interferon? Reference umber: C14499-A / Effective Date: 12/03/2018 3
[o further questions.] Circle es or o 20.Has the member received 8 weeks of treatment with Promacta OR has the dose been increased to the maximum of 100 mg? 21.Is the dose of Promacta being increased? OTE: The dose should be increased by 25 mg every 2 weeks until platelets are at least 90,000 or to a maximum of 100 mg. OTE: For platelets less than 50,000/mm3 after 2 weeks of treatment, increase the dose by 25 mg per day; do not exceed 100 mg per day. For platelets 50,000/mm3 to less than 200,000/mm3, continue current dose. For platelets 200,000 to 400,000/mm3 at any time, decrease the dose by 25 mg per day. [o further questions.] 22.Does the member have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)? [If no, skip to question 27.] 23.Is the disease relapsed or refractory? 24.Has the member had an insufficient response to corticosteroids, immunoglobulins, or splenectomy? If yes, please document prior therapies or submit records: 25.Is Promacta being used to prevent major bleeding in a member with a platelet count of less than 30,000/mm3? OTE: Promacta is not approved to achieve platelet counts in the normal range (150,000-450,000/mm3) OTE: Lab results for platelets must be submitted with request. Requests 26.Is the member at least 1 year of age? Reference umber: C14499-A / Effective Date: 12/03/2018 4
[o further questions.] Circle es or o 27.Is Promacta requested to treat thrombocytopenia in a member with chronic hepatitis C infection? [If no, skip to question 31.] 28.Does the member have severe thrombocytopenia, defined as a platelet count of less than 90,000/mm3, which prevents initiation or ability to maintain interferon-based therapy? OTE: Lab results for platelets must be submitted with request. Requests 29.Does the provider attest that the member s complete blood count (CBC) with differentials and platelet counts will be monitored weekly until a stable platelet count is achieved? 30.Does the provider attest that clinical hematology and liver tests will be completed regularly throughout therapy with Promacta? [If yes, skip to question 35.] 31.Does the member have a diagnosis of severe aplastic anemia confirmed by bone marrow biopsy showing less than 25 percent of normal cellularity? OTE: Medical records to support diagnosis must be submitted with request. Requests without records will not be accepted. [If yes, skip to question 33.] 32.Does the member have a diagnosis of severe aplastic anemia confirmed by bone marrow biopsy showing less than 50 percent of normal cellularity AD at least TWO of the following: A) absolute neutrophil count (AC) less than 500/mm3; B) platelet count less than 20,000/mm3; C) absolute reticulocyte count less than 40,000/mm3? OTE: Medical records and lab results to support diagnosis must be submitted with request. Requests without records will not be accepted. 33.Is the anemia refractory to first line treatment with either hematopoietic cell Reference umber: C14499-A / Effective Date: 12/03/2018 5
Circle es or o transplantation OR immunosuppressive therapy with a combination of cyclosporine A and antithymocyte globulin (ATG)? OTE: Documentation of previous treatment must be included with request. [If yes, skip to question 35.] 34.Does the member have a contraindication to first line treatment with either hematopoietic cell transplantation OR immunosuppressive therapy with a combination of cyclosporine A and antithymocyte globulin (ATG)? 35.Is the member at least 18 years old? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C14499-A / Effective Date: 12/03/2018 6