Skip to content
The Policy VaultThe Policy Vault

Filspari (sparsentan) — Blue Cross Blue Shield of Alabama

Primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy in adults at risk for disease progression

Initial criteria

  • - The patient has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
  • - The requested agent will be used to slow kidney function decline in a patient at risk for disease progression
  • - ONE of the following: • The patient has a urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g • The patient has proteinuria ≥ 0.5 g/day
  • - The patient’s eGFR is ≥ 30 mL/min/1.73 m^2
  • - If the patient has an FDA labeled indication, then ONE of the following: • The patient’s age is within FDA labeling for the requested indication for the requested agent • There is support for using the requested agent for the patient’s age for the requested indication
  • - The patient has ONE of the following: • Tried and had an inadequate response after at least a 3‑month duration of therapy with a maximally tolerated angiotensin-converting‑enzyme inhibitor (ACEi, e.g., benazepril, lisinopril) or angiotensin II blocker (ARB, e.g., losartan), or a combination medication containing an ACEi or ARB • An intolerance or hypersensitivity to an ACEi or ARB, or a combination medication containing an ACEi or ARB • An FDA labeled contraindication to ALL ACEi and ARB
  • - The patient will NOT use the requested agent in combination with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren
  • - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • - The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • - The patient has been previously approved for the requested agent through the plan’s prior authorization process
  • - The patient has had clinical benefit with the requested agent
  • - The patient will NOT use the requested agent in combination with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren
  • - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • - The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months