MedicaidPrior AuthMedium impact
Nplate® (romiplostim) (Revised)
Humana·SC · Hematology, Oncology, Internal Medicine +1 more·Medicaid
Effective date
Jan 1, 2021
We identified it
Jul 22, 2026
Summary
This is a revised Nplate (romiplostim) prior authorization policy for Medicaid in South Carolina, effective January 1, 2021, with updates as of July 22, 2026. The policy establishes coverage criteria for three indications: Persistent/Chronic ITP (requiring platelet count <30 or 30-50 with bleeding plus prior corticosteroid/IVIG trial), Chemotherapy-induced Thrombocytopenia (requiring platelet <100 during myelosuppressive chemo with treatment delay/dose reduction risk), and Hematopoietic Syndrome of Acute Radiation Syndrome. Prior authorization is required for all uses, with specific exclusions for MDS-related thrombocytopenia and certain malignancies (AML, high-risk myelodysplasia, stem cell transplant, lymphoma).
Action Required
Before submitting any Nplate claims for Medicaid (South Carolina): (1) Billing team must implement prior authorization verification in billing system for all Nplate subcutaneous solution claims. (2) Verify patient meets specific criteria based on indication: For ITP—confirm diagnosis, platelet count documentation (<30 or 30-50 with bleeding), AND evidence of prior corticosteroid or IVIG trial. For CIT—confirm diagnosis, active myelosuppressive chemotherapy for solid tumor or non-myeloid hematologic malignancy, platelet <100, and documentation that Nplate will enable planned chemotherapy (not just normalize counts). For HS-ARS—confirm acute radiation exposure diagnosis. (3) Verify patient does NOT have exclusionary diagnoses (MDS, AML, high-risk myelodysplasia, stem cell transplant, or lymphoma for CIT indication). (4) For renewals: ITP renewals require platelet <400; CIT renewals require continued myelosuppressive chemotherapy. (5) Deny claims without prior authorization or claims that do not meet documented criteria. (6) Flag any off-label uses or non-qualifying indications for clinical review. Failure to obtain prior authorization will result in claim denials and potential recoupment.