Tarpeyo — 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 of therapy, OR has an intolerance or contraindication to RAS inhibitors.
Reauthorization criteria
- All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteria section.
Approval duration
10 months