Vanrafia — Blue Cross Blue Shield of Oklahoma

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

Diagnosis of primary IgA nephropathy confirmed by kidney biopsy AND
If the patient has an FDA labeled indication, then 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) 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
ONE of the following: (A) tried and had inadequate response after at least 3 months with maximally tolerated ACE inhibitor (e.g., benazepril, lisinopril) or ARB (e.g., losartan), or combination containing an ACEi or ARB OR (B) intolerance or hypersensitivity to 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 one AND
Patient does NOT have any FDA labeled contraindications to the requested agent

Patient previously approved for the requested agent through the plan’s Prior Authorization process AND
Patient has had improvement or stabilization as indicated by ONE of the following: (A) decrease from baseline in 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

9–12 months