Zilbrysq (zilucoplan) — Highmark
generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor antibody positive (AChR Ab+)
Initial criteria
- age ≥ 18 years
- diagnosis of generalized myasthenia gravis (gMG)
- positive serologic test for anti-acetylcholine receptor antibodies (AChR Ab+)
- Myasthenia Gravis Foundation of America (MGFA) Clinical Classification Class II to IV at the start of therapy
- experienced therapeutic failure, contraindication, or intolerance to pyridostigmine
- trial and inadequate response or intolerance to one or more immunosuppressive agents (systemic corticosteroids or non-steroidal immunosuppressants)
Reauthorization criteria
- prescriber attests that the member has experienced improvement in signs and symptoms of gMG (e.g., speech, swallowing, mobility, and/or respiratory function)
- OR prescriber attests that the member has experienced a decrease in the number of exacerbations of gMG
Approval duration
12 months