iptacopan hcl cap 200 MG — Blue Cross Blue Shield of Kansas

Initial criteria

• Diagnosis of C3 glomerulopathy (C3G) confirmed by kidney biopsy
• Urine protein-to-creatinine ratio (UPCR) ≥ 0.88 g/g OR proteinuria > 1.0 g/day
• eGFR ≥ 30 mL/min/1.73 m^2
• EITHER: currently treated with a maximally tolerated ACE inhibitor or ARB (or combination) for at least a 90-day duration AND will continue ACEi or ARB therapy in combination with Fabhalta OR intolerance, hypersensitivity, or FDA-labeled contraindication to ALL ACEi, ARB, and combination medications
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with a specialist
• The agent will NOT be used in combination with Empaveli (pegcetacoplan), Soliris (eculizumab), Bkemv (eculizumab-aeeb), Epysqli (eculizumab-aagh), Ultomiris (ravulizumab-cwvz), or Piasky (crovalimab-akkz)
• The patient does NOT have any FDA-labeled contraindications to Fabhalta

Approval duration

6 months