Tarpeyo — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
• Requested agent used to reduce the loss of kidney function in a patient at risk for disease progression AND
• Urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR proteinuria ≥ 0.5 g/day AND
• eGFR ≥ 30 mL/min/1.73 m^2 AND
• Patient’s age within FDA labeling for the indication OR there is support for use in the patient’s age for the requested indication AND
• Patient has tried and had inadequate response after ≥ 3 months of therapy with maximally tolerated ACE inhibitor or ARB OR intolerance, hypersensitivity, or contraindication to all ACE inhibitors and ARBs AND
• ONE of the following regarding glucocorticoids (chart notes required): patient currently stable on requested agent OR tried and had inadequate response to one oral generic glucocorticoid OR discontinued due to lack of efficacy, diminished effect, or adverse event OR intolerance/hypersensitivity not expected with requested agent OR contraindication to all oral generic glucocorticoids OR oral generic glucocorticoid expected to be ineffective or inappropriate based on patient and drug characteristics OR not in the best interest of the patient based on medical necessity OR tried another drug in same class with failure or adverse event AND
• Patient has not previously been treated with a 9‑month course of therapy with requested agent OR has support for an additional course of therapy AND
• Prescriber is a specialist in the area of patient’s diagnosis (e.g., nephrologist) or has consulted with one AND
• Patient does not have any FDA labeled contraindications to requested agent

Approval duration

12 months (BCBSIL/BCBSMT); 10 months (others)