Thrombocytopenia Drugs

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PDL Reference Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
71369001030 DOPTELET SPRINKLE avatrombopag maleate CAP SPRINK 10 mg N Y N Pharmacy PA
71369002010 DOPTELET avatrombopag maleate TABLET 20 mg N Y N Pharmacy PA
71369002011 DOPTELET avatrombopag maleate TABLET 20 mg N Y N Pharmacy PA
71369002015 DOPTELET avatrombopag maleate TABLET 20 mg N Y N Pharmacy PA
71369002016 DOPTELET avatrombopag maleate TABLET 20 mg N Y N Pharmacy PA
71369002030 DOPTELET avatrombopag maleate TABLET 20 mg N Y N Pharmacy PA
00480327456 ALVAIZ eltrombopag choline TABLET 18 mg N Y N Pharmacy PA
00480327556 ALVAIZ eltrombopag choline TABLET 36 mg N Y N Pharmacy PA
00480327656 ALVAIZ eltrombopag choline TABLET 54 mg N Y N Pharmacy PA
00480327356 ALVAIZ eltrombopag choline TABLET 9 mg N Y N Pharmacy PA
31722030012 ELTROMBOPAG OLAMINE eltrombopag olamine POWD PACK 12.5 mg Y Y N  
31722030032 ELTROMBOPAG OLAMINE eltrombopag olamine POWD PACK 12.5 mg Y Y N  
00078097219 PROMACTA eltrombopag olamine POWD PACK 12.5 mg Y Y N  
00078097223 PROMACTA eltrombopag olamine POWD PACK 12.5 mg Y Y N  
00078097261 PROMACTA eltrombopag olamine POWD PACK 12.5 mg Y Y N  
31722030125 ELTROMBOPAG OLAMINE eltrombopag olamine POWD PACK 25 mg Y Y N  
31722030132 ELTROMBOPAG OLAMINE eltrombopag olamine POWD PACK 25 mg Y Y N  
00078069719 PROMACTA eltrombopag olamine POWD PACK 25 mg Y Y N  
00078069723 PROMACTA eltrombopag olamine POWD PACK 25 mg Y Y N  
00078069761 PROMACTA eltrombopag olamine POWD PACK 25 mg Y Y N  
31722084130 ELTROMBOPAG OLAMINE eltrombopag olamine TABLET 12.5 mg Y Y N  
00078068415 PROMACTA eltrombopag olamine TABLET 12.5 mg Y Y N  
31722084230 ELTROMBOPAG OLAMINE eltrombopag olamine TABLET 25 mg Y Y N  
00078068515 PROMACTA eltrombopag olamine TABLET 25 mg Y Y N  
31722084330 ELTROMBOPAG OLAMINE eltrombopag olamine TABLET 50 mg Y Y N  
00078068615 PROMACTA eltrombopag olamine TABLET 50 mg Y Y N  
00078068655 PROMACTA eltrombopag olamine TABLET 50 mg Y Y N  
31722084430 ELTROMBOPAG OLAMINE eltrombopag olamine TABLET 75 mg Y Y N  
00078068715 PROMACTA eltrombopag olamine TABLET 75 mg Y Y N  
71332000101 TAVALISSE fostamatinib disodium TABLET 100 mg N Y N Pharmacy PA
71332000201 TAVALISSE fostamatinib disodium TABLET 150 mg N Y N Pharmacy PA
59630055107 MULPLETA lusutrombopag TABLET 3 mg N Y N Pharmacy PA
00078148320 RHAPSIDO remibrutinib TABLET 25 mg N Y N Pharmacy PA
58468025106 WAYRILZ rilzabrutinib TABLET 400 mg N Y N Pharmacy PA
55513022301 NPLATE romiplostim VIAL 125 mcg Y Y N  
55513022101 NPLATE romiplostim VIAL 250 mcg Y Y N  
55513022201 NPLATE romiplostim VIAL 500 mcg Y Y N  
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