Empaveli (pegcetacoplan subcutaneous injection – Apellis) — Cigna

Initial criteria

• Patient age ≥ 12 years
• Diagnosis confirmed by biopsy
• Urine protein-to-creatinine ratio ≥ 1.0 g/g
• Estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m2
• Patient has been on stable doses of at least ONE of the following for ≥ 12 weeks prior to starting Empaveli: (a) angiotensin converting enzyme inhibitor; OR (b) angiotensin receptor blocker; OR (c) sodium-glucose cotransporter-2 inhibitor
• Medication is prescribed by or in consultation with a nephrologist

Reauthorization criteria

• Patient age ≥ 12 years
• Diagnosis confirmed by biopsy
• According to the prescriber, patient has had a response to Empaveli (e.g., reduction in urine-to-creatinine ratio from baseline, reduction in proteinuria from baseline)
• Estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m2
• Medication is prescribed by or in consultation with a nephrologist

Approval duration

initial: 6 months; reauth: 1 year