Tarpeyo — Blue Cross Blue Shield of Alabama

To reduce the loss of kidney function in adults with primary immunoglobulin A nephropathy (IgAN) who are at risk for disease progression

Initial criteria

The patient has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
AND The requested agent will be used to reduce the loss of kidney function in a patient at risk for disease progression
AND ONE of the following: The patient has a urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR The patient has proteinuria ≥ 0.5 g/day
AND The patient’s eGFR ≥ 30 mL/min/1.73 m^2
AND 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 OR There is support for using the requested agent for the patient’s age
AND 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 OR An intolerance or hypersensitivity to an ACEi or ARB, or a combination medication containing an ACEi or ARB OR An FDA labeled contraindication to ALL ACEi and ARB
AND ONE of the following: The patient has an intolerance or hypersensitivity to oral generic budesonide that is not expected to occur with the requested agent OR The patient has an FDA labeled contraindication to oral generic budesonide that is not expected to occur with the requested agent
AND ONE of the following: The patient has not previously been treated with a course of therapy (9 months) with the requested agent OR The patient has previously been treated with a course of therapy with the requested agent, AND there is support for an additional course of therapy with the requested agent
AND 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
AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

10 months