Enspryng — Blue Cross Blue Shield of Oklahoma

neuromyelitis optica spectrum disorder (NMOSD)

Initial criteria

Diagnosis of neuromyelitis optica spectrum disorder (NMOSD)
Patient is anti‑aquaporin‑4 (AQP4) antibody positive (lab test required)
Diagnosis confirmed by at least ONE of: optic neuritis OR acute myelitis OR area postrema syndrome (episode of otherwise unexplained hiccups or nausea and vomiting) OR acute brainstem syndrome OR symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD‑typical diencephalic MRI lesions OR symptomatic cerebral syndrome with NMOSD‑typical brain lesions
Patient has had ≥1 discrete clinical attack of CNS symptoms
Alternative diagnoses (e.g., multiple sclerosis, ischemic optic neuropathy) ruled out
If patient has an FDA‑labeled indication, ONE of: age within FDA labeling for the requested indication OR support for using the agent for the patient’s age for the requested indication
Prescriber is a neurologist or has consulted with a neurologist or other appropriate specialist
Prescriber has screened for hepatitis B viral (HBV) infection AND BOTH: patient does NOT have active HBV infection AND if prior infection or carrier, prescriber has consulted with a gastroenterologist or hepatologist before and during treatment
Patient does NOT have active or untreated latent tuberculosis
Patient does NOT have any FDA‑labeled contraindications to the requested agent
Patient will NOT use the requested agent in combination with rituximab, Soliris, Uplizna, or Ultomiris for the requested indication

Patient previously approved for the requested agent through plan’s prior authorization process
Patient has demonstrated clinical benefit with the requested agent
Prescriber is a neurologist or has consulted with a neurologist or other appropriate specialist
Patient does not have active HBV infection AND if prior infection or carrier, prescriber continues to consult with a gastroenterologist or hepatologist during treatment
Patient does NOT have active or untreated latent tuberculosis
Patient does NOT have any FDA‑labeled contraindications to the requested agent
Patient will NOT use the requested agent in combination with rituximab, Soliris, Uplizna, or Ultomiris for the requested indication

12 months