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avacopan — Blue Cross Blue Shield of Kansas

Adjunctive treatment of adult patients with severe active anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (granulomatosis with polyangiitis [GPA] and microscopic polyangiitis [MPA]) in combination with standard therapy including glucocorticoids

Initial criteria

  • Target Agent(s) will be approved when ALL of the following are met:
  • 1. ONE of the following:
  • A. ONE of the following:
  • 1. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
  • 2. 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
  • B. BOTH of the following:
  • 1. ONE of the following:
  • A. ALL of the following: