tolvaptan — Blue Cross Blue Shield of Kansas

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

Reauthorization criteria

• 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

Approval duration

12 months