Enspryng (satralizumab-mwge) — CareFirst (Caremark)

Initial criteria

• Anti-aquaporin-4 (AQP4) antibody positive
• Member exhibits one of the following core clinical characteristics of NMOSD: optic neuritis; acute myelitis; area postrema syndrome (episode of otherwise unexplained hiccups or nausea and vomiting); acute brainstem syndrome; symptomatic narcolepsy or acute diencephalic clinical syndrome with NMOSD-typical diencephalic MRI lesions; symptomatic cerebral syndrome with NMOSD-typical brain lesions
• The member will not receive the requested drug concomitantly with other biologics for the treatment of NMOSD

Reauthorization criteria

• The member demonstrates a positive response to therapy (e.g., reduction in number of relapses)
• The member will not receive the requested drug concomitantly with other biologics for the treatment of NMOSD

Approval duration

12 months