Enspryng (satralizumab-mwge) — Highmark
Neuromyelitis optica spectrum disorder (NMOSD)
Initial criteria
- age ≥ 18 years
- Diagnosis of NMOSD (ICD-10: G36.0)
- Prescriber attests the member is anti-aquaporin-4 (AQP4) antibody positive
- Member exhibits at least one of the following core clinical characteristics of NMOSD: optic neuritis OR acute myelitis OR area postrema syndrome 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
- Enspryng is prescribed by or in consultation with a neurologist or other healthcare provider experienced in treating NMOSD
- Prescriber submits documentation of baseline number of relapses over the last year
- Member has experienced therapeutic failure or intolerance to one immunosuppressant (e.g., mycophenolate mofetil, azathioprine, methotrexate) OR all are contraindicated
Reauthorization criteria
- Prescriber attests the member has experienced a decrease from baseline in the number of NMOSD relapses
Approval duration
initial: up to 6 months; reauthorization: up to 12 months