tolvaptan — Blue Cross Blue Shield of Kansas

autosomal dominant polycystic kidney disease (ADPKD)

Initial criteria

ONE of the following:
A. The patient has a diagnosis of autosomal dominant polycystic kidney disease (ADPKD) AND BOTH of the following:
1. The patient does not have stage 5 chronic kidney disease (CKD) AND
2. The patient is not on dialysis OR
B. The patient has another FDA labeled indication for the requested agent and route of administration OR
C. The patient has another indication that is supported in compendia (AHFS or DrugDex level 1 or 2a) for the requested agent and route of administration AND
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 AND
The patient will NOT be using the requested agent in combination with another tolvaptan agent for the requested indication AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
The patient has had clinical benefit with the requested agent AND
The patient will NOT be using the requested agent in combination with another tolvaptan agent for the requested indication AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with a specialist in the area of the patient’s diagnosis AND
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months