Promacta

Covered Uses:	All FDA approved indications not otherwise excluded from Part D.
Exclusion Criteria:	Coverage is not provided when used in combination with Nplate.
Required Medical Information:	Patients must have had an inadequate response, intolerance to, or not be a candidate for treatment with corticosteroids, immunoglobulins, or splenectomy.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:	Renewal is provided for patients who continue to have a response to therapy (for example, platelet count has increased)

Last Modified on 12/19/2012