Brand Jynarque tablets — Cigna
autosomal dominant polycystic kidney disease (ADPKD)
Preferred products
- generic tolvaptan tablets (generic Jynarque)
Initial criteria
- Patient meets the standard Tolvaptan Products – Tolvaptan (Jynarque) Prior Authorization criteria; AND
- Patient has tried generic tolvaptan tablets [documentation required]; AND
- Patient cannot take generic tolvaptan tablets (generic Jynarque) due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) between the brand and bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Approval duration
1 year