sparsentan — Blue Cross Blue Shield of Illinois

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
Requested agent will be used to slow kidney function decline in a patient at risk for disease progression
ONE of the following: (A) urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) proteinuria ≥ 0.5 g/day
eGFR ≥ 30 mL/min/1.73 m^2
If patient has FDA labeled indication: ONE of the following: (A) patient age is within FDA labeling OR (B) support exists for age use for the indication
ONE of the following: (A) tried and had inadequate response after ≥ 3 months therapy with a maximally tolerated ACE inhibitor (ACEi) or angiotensin II blocker (ARB) or combination thereof OR (B) intolerance or hypersensitivity to ACEi or ARB or combination OR (C) FDA labeled contraindication to ALL ACEi or ARB
Patient will NOT use requested agent in combination with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren
Prescriber is a specialist in area of diagnosis (e.g., nephrologist) OR has consulted with such specialist
Patient does NOT have any FDA labeled contraindications to requested agent

Patient has been previously approved for the requested agent through plan’s Prior Authorization process
Patient has had clinical benefit with requested agent
Patient will NOT use requested agent in combination with ACEi, ARB, ERA, or aliskiren
Prescriber is a specialist in area of diagnosis or has consulted with such specialist
Patient does NOT have any FDA labeled contraindications

12 months