Aqneursa — Blue Cross Blue Shield of Texas

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 weighs ≥ 15 kg AND
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., geneticist) or has consulted with a specialist AND
• 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 AND
• The patient has had clinical benefit with the requested agent AND
• The prescriber is a specialist 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

Approval duration

6–12 months