Vanrafia (atrasentan) — Blue Cross Blue Shield of Alabama

Initial criteria

• - Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
• - Patient’s age is within FDA labeling for the requested indication OR there is support for using the agent for the patient’s age
• - Urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR proteinuria ≥ 0.5 g/day
• - Estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m²
• - ONE of the following: • Tried and had an inadequate response after ≥ 3 months of therapy with a maximally tolerated ACE inhibitor (ACEi) or angiotensin II blocker (ARB), or a combination medication containing an ACEi or ARB • 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
• - Prescriber is a specialist in nephrology or has consulted with a specialist in the area of the patient’s diagnosis
• - Patient does NOT have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

• - Patient was previously approved for the requested agent through the plan’s prior authorization process
• - Patient has demonstrated improvement or stabilization with the requested agent as indicated by: • Decrease from baseline in urine protein-to-creatinine (UPCR) ratio OR • Decrease from baseline in proteinuria
• - Prescriber is a specialist in nephrology or has consulted with a specialist in the area of the patient’s diagnosis
• - Patient does NOT have any FDA-labeled contraindications to the requested agent

Approval duration

initial 9 months; renewal 12 months