atrasentan — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• ONE of the following: (A) The patient has a urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) The patient has proteinuria ≥ 0.5 g/day
• The patient’s eGFR ≥ 30 mL/min/1.73 m²
• The patient has ONE of the following: (A) Tried and had an inadequate response after ≥ 3 months therapy with a maximally tolerated ACE inhibitor or ARB (or a combination containing ACEi or ARB) OR (B) An intolerance or hypersensitivity to an ACEi or ARB (or combination) OR (C) An FDA labeled contraindication to ALL ACEi and ARB
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist), or has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had improvements or stabilization with the requested agent as indicated by ONE of the following: (A) Decrease from baseline in urine protein-to-creatinine (UPCR) ratio OR (B) Decrease from baseline in proteinuria
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist), or has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 9 months; renewal 12 months