Oprelvekin Injection Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

Prevention of severe thrombocytopenia and the reduction of the need for platelet transfusions following myelosuppressive chemotherapy in adult patients with nonmyeloid malignancies who are at high risk of severe thrombocytopenia

Exclusion Criteria

• Myeloablative chemotherapy
• Non myeloid malignancies receiving myelosuppressive anti cancer drugs associated with clinically significant incidence of febrile neutropenia

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

Oncologist

Coverage Duration

1 year

Other Criteria

Part D vs. Part B evaluation also applies