Jynarque (tolvaptan) — Highmark
autosomal dominant polycystic kidney disease (ADPKD) with rapid progression
Initial criteria
- age ≥ 18 years
- Jynarque is prescribed by or in consultation with a nephrologist
- diagnosis of rapidly progressing autosomal dominant polycystic kidney disease supported by one of the following: historical decline in eGFR ≥ 3 mL/min/1.73 m2 per year OR Mayo imaging classification of 1C, 1D, or 1E
- member does not have stage 5 chronic kidney disease
- member is not receiving dialysis
Reauthorization criteria
- prescriber attests that decline in kidney function (e.g., TKV, eGFR) has slowed
- member does not have stage 5 chronic kidney disease
- member is not receiving dialysis
Approval duration
12 months