Filspari — Blue Cross Blue Shield of Oklahoma

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
Used to slow kidney function decline in a patient at risk for disease progression AND
ONE of the following: (A) Urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR (B) Proteinuria ≥ 0.5 g/day AND
eGFR ≥ 30 mL/min/1.73 m^2 AND
If the patient has an FDA labeled indication, ONE of the following: (A) Patient’s age is within FDA labeling for the requested indication 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) Tried and had an inadequate response after ≥ 3-month therapy with a maximally tolerated ACE inhibitor (e.g., benazepril, lisinopril) or angiotensin II blocker (e.g., losartan), or a combination containing ACEi or ARB OR (B) Intolerance or hypersensitivity to an ACEi or ARB or a combination containing ACEi or ARB OR (C) FDA labeled contraindication to ALL ACEi or ARB AND
Will NOT use with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren 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

Patient was previously approved for the requested agent through the plan’s Prior Authorization process AND
Patient has had clinical benefit with the requested agent AND
Will NOT use with an ACE inhibitor, ARB, ERA, or aliskiren 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

12 months