OH Formulary Restriction:

If use is non-oncologic, restrictions:

• • Indication: Treatment refractory Membranous Nephropathy 
  • Service Line: Nephrology
  • Formulary Location: Outpatient infusion
  • Service location: outpatient infusion, home infusion 
  • Patient Population: Adults
  • Prior Authorization Required: yes
  • Restriction/Criteria of Use (all will apply unless specified): 
• Patient does not have an active infection
• Patient has not received a live vaccine within 28 days prior to starting treatment and live vaccines will not be administered concurrently while on treatment
• Anti-PLA2R antibody positive
• Tried and failed, intolerance, contraindicated, or adverse effects to previous regimens including rituximab, cyclophosphamide + glucocorticoids, and calcineurin inhibitor

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