atrasentan — CareFirst (Caremark)
Primary immunoglobulin A nephropathy (IgAN)
Initial criteria
- Member has a diagnosis of primary immunoglobulin A nephropathy (IgAN) confirmed by kidney biopsy
- Member has either of the following: proteinuria ≥ 1 g/day OR urine protein-to-creatinine ratio (UPCR) ≥ 0.8 g/g
- Member is receiving a stable dose of maximally tolerated renin-angiotensin system (RAS) inhibitor therapy (e.g., angiotensin converting enzyme inhibitor [ACEI] or angiotensin II receptor blocker [ARB]) for at least 3 months, OR member has an intolerance or contraindication to RAS inhibitors
Reauthorization criteria
- Member is currently receiving the requested medication
- Member is experiencing benefit from therapy as evidenced by either of the following: decreased levels of proteinuria from baseline OR decrease in UPCR from baseline
Approval duration
12 months