Filspari — Blue Cross Blue Shield of New Mexico

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

1. Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
2. Requested agent will be used to slow kidney function decline in a patient at risk for disease progression AND
3. ONE of the following: (A) urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) proteinuria ≥ 0.5 g/day AND
4. eGFR ≥ 30 mL/min/1.73 m^2 AND
5. If the patient has an FDA labeled indication, then ONE of: (A) patient’s age within FDA labeling for the requested indication OR (B) support for use at patient’s age for the indication AND
6. ONE of the following: (A) Tried and had inadequate response after ≥3-month therapy with maximally tolerated ACE inhibitor or ARB or combination containing ACEi/ARB OR (B) intolerance or hypersensitivity to ACEi or ARB OR (C) FDA labeled contraindication to ALL ACEi/ARB AND
7. Patient will NOT use requested agent in combination with ACEi, ARB, ERA (e.g., bosentan), or aliskiren AND
8. Prescriber is a specialist in the area of the diagnosis (e.g., nephrologist) or has consulted with a specialist AND
9. Patient does NOT have any FDA labeled contraindications to the requested agent

1. Patient previously approved for the requested agent through plan’s Prior Authorization process AND
2. Patient has had clinical benefit with the requested agent AND
3. Patient will NOT use the agent in combination with ACEi, ARB, ERA, or aliskiren AND
4. Prescriber is a specialist in the area of diagnosis (e.g., nephrologist) or has consulted with a specialist AND
5. Patient does NOT have any FDA labeled contraindications to the requested agent

12 months