Vanrafia — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy 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
• ONE of the following: (A) The patient has a urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) The patient has proteinuria ≥ 0.5 g/day AND
• The patient’s eGFR ≥ 30 mL/min/1.73 m^2 AND
• ONE of the following: (A) Tried and had inadequate response after ≥ 3-month therapy with a maximally tolerated ACE inhibitor (ACEi, e.g., benazepril, lisinopril) or ARB (e.g., losartan), or a combination medication containing an ACEi or ARB OR (B) Intolerance or hypersensitivity to an ACEi or ARB, or combination containing an ACEi or ARB OR (C) FDA labeled contraindication to ALL ACEi and ARB AND
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with a specialist AND
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• Patient has had improvements or stabilization with the requested agent as indicated by ONE of the following: (A) Decrease from baseline in urine protein-to-creatinine ratio (UPCR) OR (B) Decrease from baseline in proteinuria AND
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with a specialist AND
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX); 9 months (others)