Fabhalta — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has not received a kidney transplant in the past; AND
• Diagnosis has been confirmed by biopsy; AND
• Patient has a urine protein-to-creatinine ratio ≥ 1.0 g/g; AND
• Patient has an estimated glomerular filtration rate ≥ 30 mL/min/1.73 m2; AND
• Patient has received the maximum or maximally tolerated dose of ONE of the following for ≥ 90 days prior to starting Fabhalta: Angiotensin converting enzyme inhibitor OR Angiotensin receptor blocker; AND
• Medication is prescribed by or in consultation with a nephrologist

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Patient has not received a kidney transplant in the past; AND
• Diagnosis has been confirmed by biopsy; AND
• According to the prescriber, patient has had a response to Fabhalta (examples: reduction in urine protein-to-creatinine ratio from baseline, reduction in proteinuria from baseline); AND
• Patient has an estimated glomerular filtration rate ≥ 30 mL/min/1.73 m2; AND
• Medication is prescribed by or in consultation with a nephrologist

Approval duration

initial 6 months; reauth 1 year