budesonide delayed release cap — Blue Cross Blue Shield of Texas

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

Diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
Requested agent will be used to reduce the loss of kidney function in a patient at risk for disease progression AND
Urine protein-to-creatinine ratio (UPCR) ≥ 0.44 g/g OR proteinuria ≥ 0.5 g/day AND
eGFR ≥ 30 mL/min/1.73 m^2 AND
Patient’s age is within FDA labeling for the requested indication OR support exists for requested agent use for the patient’s age AND
Patient has tried and had an inadequate response after ≥ 3 months of therapy with a maximally tolerated ACE inhibitor or angiotensin II receptor blocker (ARB) OR has intolerance, hypersensitivity, or FDA labeled contraindication to all ACEi/ARB AND
Patient is currently being treated and stable on requested agent OR has tried and had inadequate response to ONE oral generic glucocorticoid OR glucocorticoid was discontinued or not tolerated or contraindicated OR glucocorticoid expected ineffective or not in patient’s best interest OR tried another drug in same pharmacologic class with inadequate response (chart notes required) AND
Patient has not previously been treated with a course of therapy (9 months) with requested agent OR has support for additional course of therapy AND
Prescriber is a specialist in area of patient’s diagnosis (e.g., nephrologist) or has consulted with one AND
Patient does NOT have any FDA labeled contraindications to the requested agent

10–12 months