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Filspari — Blue Cross Blue Shield of Texas

primary immunoglobulin A nephropathy (IgAN)

Initial criteria

  • The patient has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy AND
  • The requested agent will be used to slow kidney function decline in a patient at risk for disease progression 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
  • 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
  • The patient has ONE of the following: (A) Tried and had an inadequate response after at least a 3‑month duration of therapy with a maximally tolerated ACE inhibitor (ACEi, e.g., benazepril, lisinopril) or angiotensin II receptor blocker (ARB, e.g., losartan), or a combination medication containing an ACEi or ARB OR (B) An intolerance or hypersensitivity to an ACEi or ARB, or a combination medication containing an ACEi or ARB OR (C) An FDA labeled contraindication to ALL ACEi or ARB AND
  • The patient will NOT use the requested agent in combination with an ACEi, ARB, endothelin receptor antagonist (ERA, e.g., bosentan), or aliskiren AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with such a specialist AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • The patient has had clinical benefit with the requested agent AND
  • The patient will NOT use the requested agent in combination with an ACEi, ARB, ERA, or aliskiren AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., nephrologist) or has consulted with such a specialist AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months