tolvaptan — CareFirst (Caremark)

To slow kidney function decline in adults at risk of rapidly progressing autosomal dominant polycystic kidney disease (ADPKD)

Initial criteria

The member is age ≥ 18 years with a diagnosis of ADPKD confirmed by one of the following:
- In members aged 18 to <40 years with a first-degree relative with ADPKD: ≥3 cysts (unilateral or bilateral) using any radiologic method
- In members aged 40 to <60 years with a first-degree relative with ADPKD: ≥2 cysts per kidney using any radiologic method
- In members aged ≥60 years with a first-degree relative with ADPKD: ≥4 cysts per kidney using any radiologic method
- In members with no family history (no first-degree relative with disease): positive genetic test for ADPKD (mutation in PKD1 or PKD2 gene)
The member has or is at risk for rapidly progressing disease as confirmed by height‑adjusted total kidney volume compatible with Mayo class 1C, 1D, or 1E disease
The member’s estimated glomerular filtration rate (eGFR) ≥25 mL/min/1.73 m²

Member has demonstrated a beneficial response to Jynarque therapy (e.g., slowed kidney function decline, decreased kidney pain)
Member’s estimated glomerular filtration rate (eGFR) ≥25 mL/min/1.73 m²

12 months