Tavneos (avacopan) — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following: • The patient has been treated with the requested agent within the past 90 days (starting on samples is not approvable) OR • The prescriber states the patient has been treated with the requested agent within the past 90 days (starting on samples is not approvable) AND is at risk if therapy is changed OR • BOTH of the following apply: – The patient has a diagnosis of severe active ANCA-associated vasculitis (GPA and/or MPA) AND a positive ANCA test – The patient has been screened for prior or current hepatitis B infection AND if positive a prescriber specializing in hepatitis B treatment has been consulted OR • BOTH of the following apply: – The patient has another FDA labeled indication and route of administration for the requested agent – The patient has been screened for prior or current hepatitis B infection AND if positive a prescriber specializing in hepatitis B treatment has been consulted 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 for the requested indication AND • The patient does NOT have severe hepatic impairment (Child-Pugh C) AND If the patient has a diagnosis of ANCA-associated vasculitis then BOTH of the following: • The patient is currently treated with standard therapy (e.g., azathioprine, cyclophosphamide, methotrexate, rituximab, mycophenolate mofetil) • The patient will continue standard therapy in combination with the requested agent for the requested indication