Pharmacy Prior Authorization Criteria

Mulpleta (lusutrombopag)

Indications for Prior Authorization

Mulpleta (lusutrombopag)

• For diagnosis of Thrombocytopenia
  Indicated for the treatment of thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure.

Criteria

Mulpleta

Prior Authorization

Length of Approval: 1 Month(s)

• Diagnosis of thrombocytopenia
AND
• Baseline platelet count is less than 50,000/mcL
AND
• Patient has chronic liver disease
AND
• Patient is scheduled to undergo a procedure
AND
• Trial and failure, contraindication, or intolerance to Doptelet (avatrombopag maleate)

P & T Revisions

2024-10-29, 2024-03-06, 2023-03-02, 2022-03-01, 2021-03-03, 2020-01-16

References

1. Mulpleta Prescribing Information. Shionogi Inc. Florham Park, NJ. April 2020.

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Revision History

• 2024-10-29: Addition of trial through Doptelet.
• 2024-03-06: Annual review: Background updates.
• 2023-03-02: Annual review: Background updates.
• 2022-03-01: 2022 Annual Review - no changes to criteria, updated background information
• 2021-03-03: 2021 Annual Review, no changes to criteria.
• 2020-01-16: 2020 Annual Review - No changes to criteria.

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