Aqneursa — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. The patient has a diagnosis of Niemann-Pick disease Type C AND
• 2. Genetic analysis confirms mutation in the NPC1 or NPC2 genes AND
• 3. The patient has disease-related neurological symptoms AND
• 4. The patient weighs ≥ 15 kg AND
• 5. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist) or has consulted with a specialist AND
• 6. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist) or has consulted with a specialist AND
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months