Aqneursa (levacetylleucine) — Blue Cross Blue Shield of Oklahoma

Niemann-Pick disease Type C

Initial criteria

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

BCBSIL plans: 12 months; All other plans: 6 months; Renewal: 12 months