sparsentan — Blue Cross Blue Shield of Kansas

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
Requested agent will be used to slow kidney function decline in a patient at risk for disease progression
ONE of the following: (A) Urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) Proteinuria ≥ 0.5 g/day
eGFR ≥ 30 mL/min/1.73 m^2
If the patient has an FDA labeled indication, then ONE of the following: (A) Age within FDA labeling for the requested indication for the requested agent OR (B) Support for use of the agent for the patient's age for the requested indication
ONE of the following: (A) Tried and had an inadequate response after at least 3-month duration of therapy with a maximally tolerated ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB), or a combination medication containing an ACEi or ARB OR (B) Intolerance or hypersensitivity to an ACEi or ARB, or a combination medication containing an ACEi or ARB OR (C) FDA-labeled contraindication to ALL ACEi and ARB
Will NOT use requested agent in combination with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren
Prescriber is a specialist in nephrology or has consulted with a nephrologist
Patient does NOT have any FDA labeled contraindications to the requested agent

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Patient will NOT use the requested agent in combination with an ACEi, ARB, ERA, or aliskiren

12 months