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Enspryng — Blue Cross Blue Shield of New Mexico

neuromyelitis optica spectrum disorder (NMOSD)

Initial criteria

  • 1. The patient has a diagnosis of neuromyelitis optica spectrum disorder (NMOSD)
  • 2. The patient is anti-aquaporin-4 (AQP4) antibody positive (lab test required)
  • 3. The diagnosis was confirmed by at least ONE of the following: A. Optic neuritis OR B. Acute myelitis OR C. Area postrema syndrome (episode of otherwise unexplained hiccups or nausea and vomiting) OR D. Acute brainstem syndrome OR E. Symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions OR F. Symptomatic cerebral syndrome with NMOSD-typical brain lesions
  • 4. The patient has had at least 1 discrete clinical attack of CNS symptoms
  • 5. Alternative diagnoses (e.g., multiple sclerosis, ischemic optic neuropathy) have been ruled out
  • 6. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication
  • 7. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • 8. The prescriber has screened the patient for hepatitis B viral (HBV) infection AND BOTH of the following: A. The patient does NOT have an active HBV infection AND B. If the patient has had a previous HBV infection or is a carrier for HBV infection the prescriber has consulted with a gastroenterologist or a hepatologist before initiating and during treatment with the requested agent
  • 9. The patient does NOT have active or untreated latent tuberculosis
  • 10. The patient does NOT have any FDA labeled contraindications to the requested agent
  • 11. The patient will not be using the requested agent in combination with rituximab, Soliris, Uplizna, or Ultomiris for the requested indication

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • 2. The patient has had clinical benefit with the requested agent
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • 4. BOTH of the following: A. The patient does not have active hepatitis B infection AND B. If the patient has had a previous HBV infection or is a carrier for HBV infection the prescriber continues to consult with a gastroenterologist or a hepatologist during treatment with the requested agent
  • 5. The patient does NOT have active or untreated latent tuberculosis
  • 6. The patient does NOT have any FDA labeled contraindications to the requested agent
  • 7. The patient will NOT be using the requested agent in combination with rituximab, Soliris, Uplizna, or Ultomiris for the requested indication

Approval duration

12 months