iptacopan hcl cap 200 MG — Blue Cross Blue Shield of Kansas
Other FDA-labeled indications for Fabhalta
Initial criteria
- Patient has an FDA-labeled indication for the requested agent and route of administration
- The patient’s age is within FDA labeling for the requested indication OR there is support for using the agent at the patient’s age
- Prescriber is a specialist in the area of the patient’s diagnosis 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
12 months