Aqneursa — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND ONE of the following: (1) The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR (2) The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR (B) ALL of the following: (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
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist) or has consulted with one
• The patient does not have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

initial 6 months; reauth 12 months