arimoclomol citrate — Blue Cross Blue Shield of Montana

Niemann-Pick disease Type C

Initial criteria

Either (A) the requested agent is eligible for continuation of therapy and patient has been treated with the requested agent within past 90 days and is at risk if therapy is changed OR (B) all of the following:
The patient has a diagnosis of Niemann-Pick disease Type C
Genetic analysis confirms mutation in NPC1 or NPC2 genes
The patient has disease-related neurological symptoms
The requested agent will be used in combination with miglustat
If the patient has an FDA labeled indication, the patient’s age is within FDA labeling for that indication OR there is support for use for the patient’s age
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist) or has consulted with a specialist
The patient does NOT have any FDA labeled contraindications to the requested agent

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 a specialist
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months