Pharmacy Prior Authorization Criteria

Wayrilz (rilzabrutinib)

Indications for Prior Authorization

Wayrilz (rilzabrutinib)

• For diagnosis of Immune thrombocytopenia (ITP)
  Indicated for the treatment of adult patients with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment.

Criteria

Wayrilz

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of one of the following:
• Persistent immune thrombocytopenia (ITP)
• Chronic ITP
• Relapsed/refractory ITP
AND
• Baseline platelet count is less than 30,000/mcL
AND
• One of the following:
• Patient has had a prior splenectomy
OR
• Trial and failure, contraindication, or intolerance to ONE of the following:
• Corticosteroids (e.g., prednisone, methylprednisolone)
• Immunoglobulins [e.g., Gammagard, immune globulin (human)]
AND
• Trial and failure, contraindication, or intolerance to generic eltrombopag olamine
AND
• Prescribed by or in consultation with a hematologist/oncologist

Wayrilz

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy as evidenced by an increase in platelet count to a level sufficient to avoid clinically important bleeding

P & T Revisions

2025-10-17, 2025-10-16, 2025-10-10

References

1. Wayrilz Prescribing Information.Genzyme Corporation Cambridge, MA 02141. August 2025.
2. Neunert C, Terrell D, Arnold D, et al. The American Society of Hematology 2019 Evidence-based practice guideline for immune thrombocytopenia. Available at: https://ashpublications.org/bloodadvances/article/3/23/3829/429213/American-Society-of-Hematology-2019-guidelines-for. Accessed September 19, 2025.

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Revision History

• 2025-10-17: New program.
• 2025-10-16: New program.
• 2025-10-10: New program.

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