Anthem Blue Cross (HMO, PPO, EPO)
Nplate (romiplostim)
Drugs for the Blood : Drugs for the Blood
  • Step Therapy: Immune Thrombocytopenic Purpura (ITP):
    ST Single Generic

  • Available only through Specialty Pharmacy;
    For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click  HERE;
  • Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Immune Thrombocytopenic Purpura (ITP):
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)
    Diagnosis Types: Chronic Immune Thrombocytopenia
    Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
    Reauthorization Requirements Documented in Policy: 2 of Platelet count >=50,000/mcL and <=100,000/mcL;Response to therapy as evidenced by increased platelet count
    Required Medical Information: 2 of Documentation of diagnosis;Platelet count
    Supporting Documentation Must Be Submitted: Yes

  • PA Applies