levacetylleucine — Blue Cross Blue Shield of Montana

Initial criteria

• 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 patient weighs ≥ 15 kg
• 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

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

Approval duration

12 months