ALL of the following

• Actemra (tocilizumab) - Exclusion: concurrent use with a Biologic DMARD or Targeted Synthetic DMARD is not allowed.
• Initial therapy: Indication-specific criteria (e.g., RA, GCA, SJIA, PJIA) - age limits apply (GCA/RA ≥18; PJIA/SJIA ≥2 for initial). Prescriber restriction: rheumatologist or in consultation with one for RA, GCA, PJIA, SJIA initial therapy.
• RA initial: patient has tried ONE of Enbrel, a preferred adalimumab product, Rinvoq, or Xeljanz/XR (or prior trials with Cimzia, Kevzara, infliximab, golimumab SC/IV, Orencia, or a non-preferred adalimumab can count); OR patient has heart failure or prior lymphoproliferative disorder.
• PJIA initial: tried ONE of Enbrel, Rinvoq, Xeljanz, preferred adalimumab product (or prior trials with Kevzara, infliximab, Orencia, or non-preferred adalimumab count); OR heart failure or prior lymphoproliferative disorder. SJIA/systemic-onset JIA: approve for initial therapy.
• Giant Cell Arteritis initial: patient has tried or is currently taking systemic corticosteroid or corticosteroid is contraindicated.
• Interstitial lung disease indication: age ≥18 for initial and continuation; diagnosis confirmed by HRCT and elevated acute phase reactants as required per indication-specific rules.
• Continuation therapy (all indications): prescriber documents patient response to therapy. Coverage duration: approve through end of plan year for most Actemra indications.

ALL of the following

• ARIKAYCE (amikacin liposome inhalation) - Initial therapy: Mycobacterium avium complex (MAC) lung disease in adults - ALL of the following must be met:

• ALL of the following

  • A) Positive sputum culture for MAC (any positive culture after completion of a background multidrug regimen also meets criterion).
  • B) MAC isolate susceptible to amikacin.
  • C) ARIKAYCE will be used in combination with a background multidrug regimen (example regimen: macrolide [azithromycin or clarithromycin], ethambutol, and a rifamycin [rifampin or rifabutin]).
• Prescriber restriction: pulmonologist, infectious disease physician, or physician specializing in MAC lung infections. Age restriction: ≥18 (initial). Coverage duration: 1 year.
• Continuation therapy: ARIKAYCE prescribed with background multidrug regimen AND patient either (a) has not achieved negative sputum cultures for MAC or (b) has achieved negative sputum cultures for less than 12 months.

ALL of the following

• ARCALYST (rilonacept) - Exclusion: concurrent biologic therapy.
• Initial therapy age restriction: CAPS/pericarditis ≥12 years. Prescriber restrictions: CAPS - rheumatologist, geneticist, allergist/immunologist, or dermatologist; DIRA initial - rheumatologist/geneticist/dermatologist/physician specializing in autoinflammatory disorders; Pericarditis - cardiologist or rheumatologist.
• Initial therapy DIRA: patient weighs ≥10 kg, genetic test confirming bi-allelic pathogenic IL1RN variants, and prior clinical benefit with anakinra SC injection.
• Pericarditis: recurrent pericarditis required for initial approval.
• Continuation: patient demonstrated response to therapy for all indications. Coverage durations: CAPS 3 months initial/1 year continuation; DIRA 6 months initial/1 year continuation; Pericarditis 3 months initial/1 year continuation.

ALL of the following

• Benlysta (belimumab) - Exclusion: concurrent use with other biologics or with Lupkynis per product policies where applicable.
• Indications: SLE and lupus nephritis per FDA labeling. Age restriction: ≥5 years (initial). Prescriber: SLE - rheumatologist, clinical immunologist, nephrologist, neurologist or dermatologist for initial and continuation; lupus nephritis - nephrologist or rheumatologist.
• SLE initial: autoantibody-positive SLE (ANA and/or anti-dsDNA) AND Benlysta used concurrently with at least one other standard therapy (antimalarials, systemic corticosteroid, and/or other immunosuppressants) unless intolerant to standard therapy.
• Lupus nephritis initial: biopsy-confirmed lupus nephritis (eg WHO class III, IV, V) AND Benlysta used with an immunosuppressive regimen (eg azathioprine, cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil and/or systemic corticosteroid).
• Continuation: Benlysta used concurrently with at least one other standard therapy (unless intolerant) AND patient has responded to therapy (subcutaneous or IV) as documented by prescriber. Coverage duration: SLE initial 4 months/cont 1 year; lupus nephritis initial 6 months/cont 1 year.

ALL of the following

• Blenrep (belantamab mafodotin) - Approve according to FDA-approved indications and standard oncology criteria; prescriber restriction: oncologist; coverage duration: 1 year. Approve in relapsed/refractory multiple myeloma per product labeling and oncology practice standards (e.g., prior lines of therapy as required).

ALL of the following

• Ibandronate IV - Indications: Treatment of postmenopausal osteoporosis. Exclusion: concurrent use with other osteoporosis medications as specified.
• Coverage duration: authorization for 12 months.
• Initial authorization requires ONE of the following: 1) T-score ≤ -2.5 at lumbar spine, femoral neck, or total hip (current or prior); 2) History of osteoporotic or fragility fracture; 3) T-score between -1.0 and -2.5 and physician determines patient at high risk for fracture AND inadequate response to oral bisphosphonate therapy after a 12-month trial or intolerability to oral bisphosphonate (eg severe GI adverse effects), inability to swallow or remain upright, pre-existing GI condition; OR prior trial of IV bisphosphonate (ibandronate or zoledronic acid); OR patient has osteoporotic/fragility fracture.

ALL of the following

• Ambrisentan / Bosentan (endothelin receptor antagonists) - Indications: Pulmonary arterial hypertension (PAH) WHO Group 1; bosentan may also be used for chronic thromboembolic pulmonary hypertension (CTEPH) in selected cases per policy.
• Required: Right-heart catheterization results confirming PAH for WHO Group 1 indications. Prescriber restriction: cardiology or pulmonology consultation required for PAH; CTEPH - cardiologist or pulmonologist.
• Other criteria for CTEPH with bosentan: patient must have tried Adempas, have a contraindication to Adempas, or be currently receiving bosentan for CTEPH. Coverage duration: 1 year.

ALL of the following

• Braftovi (encorafenib) - Approval requires diagnosis and documented BRAF V600 mutation (or BRAF V600E) status as applicable.
• Melanoma: unresectable, advanced or metastatic melanoma with BRAF V600 mutation. Colon/rectal cancer: BRAF V600E mutation-positive disease and use in combination with anti-EGFR therapy (cetuximab/panitumumab) and chemotherapy per regimens described (e.g., FOLFOX) or in previously treated disease with EGFR combination. NSCLC: BRAF V600E mutation-positive recurrent/advanced/metastatic disease when used in combination with MEK inhibitor Mektovi (binimetinib). Appendiceal adenocarcinoma: BRAF V600E positive advanced/metastatic disease in combination with cetuximab or panitumumab. Coverage duration: 1 year; age ≥18 for listed oncology uses.

ALL of the following

• CIMZIA (certolizumab pegol) - Exclusion: concurrent use with a Biologic DMARD or Targeted Synthetic DMARD.
• Required medical information: diagnosis, concurrent medications, previous therapies tried. Age restrictions: generally ≥18 for AS, nr-axSpA, PsA, RA, CD, and PP initial therapy; JIA ≥2 years initial.
• Prescriber restrictions: RA/AS/JIA initial - rheumatologist; Crohn’s disease - gastroenterologist; PsA - rheumatologist or dermatologist; Plaque Psoriasis - dermatologist; nr-axSpA - rheumatologist.
• Initial therapy rules: indication-specific step-therapy requirements (examples): AS initial - tried TWO of Enbrel, preferred adalimumab, Xeljanz/XR, Cosentyx (non-preferred adalimumab counts if needed); PsA initial - tried TWO of Enbrel, preferred adalimumab, Cosentyx, Tremfya, preferred ustekinumab, Otezla, Rinvoq, Skyrizi, Xeljanz/XR; RA initial - tried two of Enbrel, preferred adalimumab, Rinvoq, or Xeljanz/XR (alternate biologic trials may count); CD initial - tried ONE prior (preferred adalimumab, preferred infliximab, preferred ustekinumab, Skyrizi, Rinvoq, or Tremfya).
• Continuation: approval if documentation of response to therapy as determined by prescriber. Coverage duration: approve through end of plan year. Part B prerequisite therapy required: Yes where specified.

ALL of the following

• Camzyos (mavacamten) - Obstructive hypertrophic cardiomyopathy (oHCM) criteria.
• Initial approval requires all of the following: (i) at least one symptom associated with oHCM (eg dyspnea, chest pain, syncope, fatigue, reduced exercise tolerance) AND New York Heart Association (NYHA) Class II or III symptoms; (ii) left ventricular hypertrophy and either maximal wall thickness ≥15 mm OR familial HCM with maximal wall thickness ≥13 mm; (iii) peak LVOT gradient ≥50 mmHg at rest or with provocation (Valsalva or post-exercise). Prescriber: cardiologist. Age: ≥18. Initial coverage duration: 8 months; continuation: 1 year with response documented and treatment established ≥8 months for continuation criteria.
• Continuation criteria: patient established on therapy ≥8 months; evidence of beneficial clinical response by objective measures or symptom stabilization/improvement; LVEF ≥50% required for continuation.

ALL of the following

• Chemet (dimercaptosuccinic acid) - Initial authorization for acute lead poisoning in pediatric patients 12 months to 18 years: approve if blood lead level >45 mcg/dL prior to starting Chemet. Prescriber should be experienced in chelation therapy (eg medical toxicologist or poison control specialist). Coverage duration: 2 months.

ALL of the following

• Cinacalcet - Indication-specific coverage. Required medical information: diagnosis and relevant labs. Prescriber restrictions: hypercalcemia due to parathyroid carcinoma - oncologist or endocrinologist consultation; primary hyperparathyroidism-related hypercalcemia - nephrologist or endocrinologist consultation; hyperparathyroidism in post-renal transplant - transplant physician/nephrologist/endocrinologist consultation.
• Coverage duration: 12 months. Other criteria: hypercalcemia due to parathyroid carcinoma - approve. Primary hyperparathyroidism - approve if failed or unable to undergo parathyroidectomy. Secondary hyperparathyroidism in CKD on dialysis - deny under Medicare Part D (submit under ESRD bundle). Hyperparathyroidism in post-renal transplant - baseline calcium and iPTH above normal prior to starting cinacalcet.

ALL of the following

• Clobazam (Sympazan) - Exclusion: N/A. Initial therapy age restriction: ≥2 years and older. Prescriber: neurologist or in consultation with one for initial therapy.
• Lennox-Gastaut initial: patient has tried and/or is concomitantly receiving one of lamotrigine, topiramate, rufinamide, felbamate, Fintepla, Epidiolex or valproic acid. Treatment-refractory seizures initial: tried/concomitantly receiving at least two other antiepileptic drugs. Continuation: prescriber confirms patient is responding to therapy. Coverage duration: 1 year.

ALL of the following

• CRYSVITA (burosumab) - Indications: X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO). Exclusion: CKD severe/ESRD.
• XLH initial: baseline serum phosphorus below normal for age AND (a) baseline TmP/GFR below normal for age and gender OR (b) genetic test confirming PHEX pathogenic variant. For patients ≥18, require current signs/symptoms of XLH. Continuation: patient deriving clinical benefit as determined by prescriber. Coverage duration: XLH initial/continuation - 1 year.
• TIO initial: mesenchymal tumor that cannot be curatively resected or identified/localized AND baseline serum phosphorus below normal for age AND baseline TmP/GFR below normal for age and gender AND current signs/symptoms of TIO. Initial 6 months; continuation 1 year if responding.

ALL of the following

• Cystagon (cysteamine) - Cystinosis (nephropathic): Prescriber/consult with nephrologist or metabolic disease specialist. Diagnosis confirmed by genetic testing showing biallelic pathogenic/likely pathogenic CTNS variants OR white blood cell cystine concentration above upper limit of normal. Coverage duration: 1 year.

ALL of the following

• Dalfampridine - Multiple sclerosis ambulatory therapy. Age ≥18. Prescriber: neurologist or MS specialist. Initial: patient ambulatory, drug intended to improve or maintain mobility, and impaired ambulation documented by objective measure (eg timed 25-foot walk, MSWS-12). Continuation: patient ambulatory and demonstrating benefit or response to therapy per prescriber. Coverage duration: 1 year.

ALL of the following

• Deferasirox - Chronic/transfusion-related iron overload. Required: serum ferritin level prior to initiation. Prescriber: hematologist. Transfusion-related chronic iron overload initial: receiving regular blood transfusions AND serum ferritin >1000 mcg/L prior to starting. Non-transfusion-dependent thalassemia syndromes initial: serum ferritin >300 mcg/L prior to starting. Continuation: patient benefiting from therapy as confirmed by prescriber. Coverage duration: 1 year.

ALL of the following

• Daurismo (glasdegib) - Acute myeloid leukemia (AML): approve when used in combination with cytarabine per labeling. Prescriber: oncologist. Coverage duration: 1 year.

ALL of the following

• Emgality (galcanezumab) - Migraine prevention and episodic cluster headache. Exclusion: concurrent combination therapy with another CGRP inhibitor for migraine prevention. Age ≥18. Required medical info: diagnosis and headache frequency. Initial migraine prevention: ≥4 migraine days per month prior to initiating; if currently on Emgality, must demonstrate significant clinical benefit (eg reduction in monthly migraine days or severe migraine days). Episodic cluster headache: 1 headache every other day to 8 headaches per day. Coverage duration: 1 year.

ALL of the following

• Enbrel (etanercept) - Exclusion: concurrent use with biologic therapy or targeted synthetic DMARD. Required: diagnosis, concurrent meds, previous therapies tried. Age restrictions vary by indication (initial RA/AS ≥18; JIA/PsA/Behcet's ≥2; GVHD ≥6; PP ≥4). Prescriber restrictions for initial therapy: RA/AS/JIA - rheumatologist; PsA - rheumatologist; PP - dermatologist; GVHD - oncologist/hematologist/ transplant-affiliated physician.
• Initial therapy step: RA/JIA/AS/PP/PsA initial require prior trials of preferred adalimumab or other specified agents per indication (eg try one preferred adalimumab). Continuation: approve if patient had response to therapy. Coverage duration: approve through end of plan year.

ALL of the following

• Diacomit (stiripentol) - Dravet Syndrome: age ≥6 months and older initial. Prescriber: neurologist. Initial approve if patient is concomitantly receiving clobazam or is unable to take clobazam due to adverse events. Continuation: approve if patient responds to therapy. Coverage duration: 1 year.

ALL of the following

• Epidiolex (cannabidiol) - Seizure indications (Dravet, Lennox-Gastaut, TSC, refractory epilepsy). Age ≥1 year for initial. Prescriber: neurologist. Initial for Dravet: tried or concomitantly receiving at least two other antiseizure drugs or has tried/receiving Diacomit, clobazam, or Fintepla. Lennox-Gastaut/TSC/refractory epilepsy: tried or concomitantly receiving at least two other antiseizure drugs. Continuation across indications: patient responding to therapy. Coverage duration: 1 year.

ALL of the following

• Ensacove (ALK inhibitor) - NSCLC with ALK rearrangement: For new starts, use preferred ALK products (Alecensa or Lorbrena) unless prescriber documents inappropriate. Approve for FDA-approved ALK-positive NSCLC indications. Coverage duration: 1 year; age ≥18.

ALL of the following

• Epkinly (epcoritamab) - Lymphoma indications: Approve for diffuse large B-cell lymphoma, follicular lymphoma, HIV-related B-cell lymphoma, post-transplant lymphoproliferative disorders per product labeling when prior systemic therapy requirements are met. Prescriber: oncologist. Coverage duration: 1 year.

ALL of the following

• Fasenra (benralizumab) - Initial asthma criteria: Age ≥6 years initial. Exclusion: concurrent use with another monoclonal antibody therapy. Prescriber: allergist, immunologist, or pulmonologist. Initial asthma: ALL of A) blood eosinophils ≥150 cells/µL within 6 weeks prior to treatment, B) patient used an inhaled corticosteroid with at least one additional controller medication, and C) uncontrolled asthma defined by one of exacerbation/system measures (systemic CS in past year, ED/hospital visit, FEV1 <80% predicted [<90% for <18], FEV1/FVC <0.80, or worsened asthma with systemic CS taper). Coverage duration: initial 6 months, continuation 12 months.
• Fasenra EGPA criteria: Age ≥18 initial; prescriber and lab/eosinophil thresholds per policy; initial EGPA requires active non-severe disease, on systemic corticosteroid ≥4 weeks, and blood eosinophils ≥150 cells/µL within prior 4 weeks or prior to any monoclonal antibody that may alter eosinophils. Continuation: documented response to therapy. Coverage durations: EGPA initial 8 months, continuation 12 months.

ALL of the following

• Fintepla (fenfluramine) - Dravet Syndrome criteria: initial approve if patient has tried or is concomitantly receiving at least two other antiepileptic drugs or has tried/concomitantly receiving Epidiolex, Clobazam or Diacomit. Continuation: responding to therapy. Age per product labeling; prescriber: neurologist. Coverage duration: 1 year.

ALL of the following

• Epk-inly / EPKINLY Dravet criteria - EPKINLY (if referencing for B-cell lymphoma or Dravet options): follow product-specific criteria - for Dravet, ensure prior antiseizure trials and neurologist involvement. For lymphoma uses, require prior lines of systemic therapy as specified and oncology prescriber.

ALL of the following

• Fabrazyme (agalsidase beta) - Fabry disease: Exclusion concurrent use with Galafold or Elfabrio. Required: diagnosis, genetic and lab test results demonstrating deficient alpha-galactosidase A activity or pathogenic GLA variant. Prescriber: geneticist, endocrinologist, metabolic disorder specialist or lysosomal storage disorder specialist. Coverage duration: 1 year.

ALL of the following

• ESA (erythropoiesis-stimulating agents) indication-specific criteria (eg Procrit/Retacrit) - Required: diagnosis and Hb thresholds per indication. Prescriber restrictions for MDS anemia/myelofibrosis: hematologist/oncologist. Coverage durations vary by indication (chemo 6 months, transfusion 1 month, CKD 1 year, etc.). Other criteria: specific Hb thresholds and prior therapy rules per indication (eg Hb <10 g/dL for certain initial therapies).

ALL of the following

• RET-targeted therapies (eg selpercatinib, pralsetinib, others) - Indications: RET fusion-positive or RET mutation-positive tumors (NSCLC, thyroid cancer, medullary/anaplastic thyroid cancer) confirmed by an FDA-approved test. Approve when disease is advanced/recurrent/metastatic and requires systemic therapy; prescriber: oncologist. Coverage duration: 1 year.

ALL of the following

• EGFR-targeted therapies (eg afatinib/Gilotrif, gefitinib) - NSCLC with sensitizing EGFR mutations (exon 19 deletion, L858R exon 21, L861Q, G719X, S768I) confirmed by approved test. Prescriber: oncologist. Coverage duration: 1 year. For squamous NSCLC: progression after platinum-based chemo for some agents as specified.

ALL of the following

• HERNEXEOS - HER2 (ERBB2) mutation-positive NSCLC: Approve for unresectable/metastatic NSCLC with activating HER2/ERBB2 mutation detected by approved test and after at least one prior systemic therapy. Coverage duration: 1 year.

ALL of the following

• Gomekli (for neurofibromatosis type 1) - Prescriber: geneticist or specialist; approve for symptomatic plexiform neurofibromas not amenable to complete resection. Coverage duration: 1 year.

ALL of the following

• Icatibant for Hereditary Angioedema (HAE) - Prescriber: allergist/immunologist or HAE specialist. Indications: treatment of acute attacks in HAE due to C1-INH deficiency (Type I/II) with diagnostic labs (low functional C1-INH <50% and low C4 at baseline). Prior icatibant responders: approve when prior favorable response documented.

ALL of the following

• ICLUSIG (ponatinib) - Indications: CML/ALL and related neoplasms per labeling. Required: Philadelphia chromosome/BCR-ABL status and T315I mutation status where applicable. Approve for T315I-positive disease or after trial of other TKIs as specified. Coverage duration: 1 year.

ALL of the following

• Growth hormone (somatropin) - Indications and testing: pediatric and adult GHD requirements include stimulation testing thresholds, IGF-1 criteria, and diagnosis-specific rules (ISS, SHOX, SGA, Noonan, Prader-Willi, CKD) with prescriber endocrinologist involvement. Coverage durations per indication (eg ISS 6 months initial, 12 months continuation). Continuation requires documented response.

ALL of the following

• HAE (C1-INH deficiency) initial therapy criteria - Diagnosis confirmed by low functional C1-INH and low C4 at baseline. Prescriber: allergist/immunologist or HAE specialist. Coverage duration: 1 year; initial therapy rules apply for on-demand and prophylactic agents per product.

ALL of the following

• Ilaris (canakinumab) - Exclusion: concurrent biologic therapy (TNF antagonists, etanercept, adalimumab, certolizumab, golimumab, infliximab), anakinra, or rilonacept. Age restrictions per indication (CAPS ≥4 yrs, SJIA/HIDS/MKD/FMF/TRAPS ≥2 yrs; Still's disease ≥18). Prescriber restrictions by indication (rheumatologist, geneticist, allergist/immunologist, dermatologist). Initial and renewal criteria per indication (eg CAPS/SJIA initial approvals; renewal requires documented response). Acute gout flare: intolerance/contraindication to NSAIDs and colchicine and receiving concomitant urate-lowering therapy unless contraindicated. FMF/HIDS/TRAPS initial: CRP ≥10 mg/L or ≥2x ULN and specified flare frequency or hospitalization history; FMF requires trial of colchicine unless contraindicated.

ALL of the following

• Imkeldi (imatinib for pediatric oral powder formulation) - Approve per product labeling; for Ph+ ALL/CML require Philadelphia chromosome/BCR-ABL status. Coverage duration: 1 year.

ALL of the following

• Inbrija (levodopa inhalation) - Indication: Parkinson's disease acute OFF episodes. Exclusion: asthma, COPD or other chronic lung disease. Required: patient is currently taking carbidopa-levodopa and experiencing OFF episodes. Prescriber: neurologist. Coverage duration: 1 year.

ALL of the following

• Testosterone therapies - Coverage criteria for hypogonadism (primary or secondary) in males: persistent signs/symptoms of androgen deficiency, two morning pre-treatment serum testosterone measurements on separate days both low per lab reference, prescriber restrictions (endocrinologist for gender-affirming care), continuing therapy requires persistent signs/symptoms and at least one pre-treatment low testosterone. Age and duration limits per indication (eg delayed puberty approvals). Coverage durations: generally 12 months; initial shorter durations for pubertal induction.

ALL of the following

• Itovebi (alpelisib) - PIK3CA-mutated breast cancer: Approve for locally advanced or metastatic HR-positive, HER2-negative, PIK3CA-mutated disease per approved test when used in combination with endocrine therapy (e.g., fulvestrant) and meeting postmenopausal or appropriate ovarian suppression criteria. Prescriber: oncology; coverage duration: 1 year.
• Itovebi (oral) initial/renewal: initial requires documented PIK3CA mutation; renewal requires clinical benefit and tolerability per prescriber.

ALL of the following

• Ivermectin - Indications: pediculosis (head/body/pubic lice) and scabies (classic, treatment-resistant, crusted, or when topical not tolerated). Coverage duration: 30 days. Off-label uses listed (eg ascariasis, enterobiasis) per policy. Prescriber: N/A. Age per labeling.

ALL of the following

• IWILFIN - Neuroblastoma: Approve for high-risk disease to reduce relapse risk when used after multiagent multimodality therapy including anti-GD2 immunotherapy AND patient has at least partial response to prior therapy. Prescriber: oncologist. Coverage duration: 1 year.

ALL of the following

• JAKAFI (ruxolitinib) - Multiple hematologic/oncologic indications: age and indication-specific rules (eg ALL 1-21 yrs, GVHD ≥12, MF/PV/accelerated/blast phase ≥18). Prescriber restrictions vary. Coverage duration: 1 year. Other criteria: PV requires prior hydroxyurea or peginterferon/ropeginterferon trial; GVHD requires prior conventional systemic treatment; other indication-specific mutation or prior therapy criteria apply.

ALL of the following

• JAYPIRCA (pirtobrutinib) / JEMPERLI (dostarlimab) - Indication-specific oncology criteria apply: JAYPIRCA for mantle cell lymphoma, CLL/SLL, Richter's transformation, MCL post-BTK trials as specified; JEMPERLI for dMMR/MSI-H solid tumors including endometrial cancer and other listed indications per product labeling. Prescriber: oncologist. Coverage duration: 1 year.

ALL of the following

• Tolvaptan (polycystic kidney disease) - Approve per product labeling for autosomal dominant polycystic kidney disease (ADPKD) with appropriate risk criteria; prescriber: nephrologist; coverage duration: as specified by policy.