Summary
Jynarque (tolvaptan) requires prior authorization. Under the initial criteria, the individual must be 18 years of age or older and have autosomal dominant polycystic kidney disease (ADPKD), must not have stage 5 chronic kidney disease (CKD), must not be on dialysis, must not use the requested agent with another tolvaptan agent, and the prescriber must be a specialist or have consulted with one. The policy history records a 05/26/2026 Pharmacy & Therapeutics revision that removed the documented diagnosis and clinical improvement requirement from the initial and renewal criteria.
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What to do
Action · 6 steps
01Prior authorization is required for Jynarque (tolvaptan).
02Run a formulary drug search on the patient's member ID to confirm the drug is covered under the member's benefit plan, since it may not be covered under a specific member's plan.
03Confirm the initial criteria are met: age 18 or older, ADPKD diagnosis, no stage 5 CKD, not on dialysis, no combination with another tolvaptan agent, prescriber is a specialist or has consulted one, no FDA labeled contraindication, and the prescribed dosage is within the program quantity limits based on the FDA approved labeled dosage.
04Approval length is 12 months.
05For renewal, confirm the individual was previously approved through the BCBSMS PA process and meets the same prescriber, combination, contraindication and quantity limit conditions.
06The use of samples by an individual will not be considered current or stable therapy to satisfy the policy requirements.
Codes mentioned
J8499Q61.2
Original notice
Jynarque (tolvaptan)
bcbsms.com · Always check the source before changing claims.
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