Empaveli — Cigna

Initial criteria

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

Reauthorization criteria

• Patient age ≥ 12 years; AND
• Diagnosis confirmed by biopsy; AND
• 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); AND
• Estimated glomerular filtration rate ≥ 30 mL/min/1.73 m2; AND
• Medication is prescribed by or in consultation with a nephrologist

Approval duration

6 months initial, 1 year reauth