Ultomiris — Medical Mutual

Generalized Myasthenia Gravis

Initial criteria

Patient had an inadequate response, contraindication, or intolerance to a trial of Vyvgart, Vyvgart Hytrulo, or Rystiggo; AND
Patient age ≥ 18 years; AND
Anti-acetylcholine receptor antibody positive generalized myasthenia gravis; AND
Myasthenia Gravis Foundation of America classification of II to IV; AND
MG-ADL score ≥ 6; AND
Patient received or is currently receiving pyridostigmine OR had inadequate efficacy, contraindication, or significant intolerance; AND
Patient received or is currently receiving two different immunosuppressant therapies for ≥ 1 year OR had inadequate efficacy, contraindication, or intolerance to two different immunosuppressants; AND
Evidence of unresolved symptoms of generalized myasthenia gravis (difficulty swallowing, breathing, mobility impairment, double vision, etc.); AND
Prescribed by or in consultation with a neurologist

Patient age ≥ 18 years; AND
Patient is continuing to derive benefit (reductions in exacerbations, improvements in speech, swallowing, mobility, respiration); AND
Prescribed by or in consultation with a neurologist

initial 6 months; reauth 12 months