Ultomiris — Medical Mutual

Neuromyelitis Optica Spectrum Disorder (NMOSD)

Initial criteria

Patient age ≥ 18 years; AND
Confirmed diagnosis of NMOSD; AND
Seropositive for aquaporin-4 IgG antibodies; AND
At least one core clinical characteristic (optic neuritis, acute myelitis, acute area postrema syndrome, acute brainstem syndrome, symptomatic narcolepsy with NMOSD-typical lesion, acute cerebral syndrome with NMOSD-typical brain lesion); AND
Alternative diagnoses excluded; AND
History of at least 1 relapse in the last 12 months; AND
Expanded Disability Status Score (EDSS) ≤ 7.0; AND
Concurrent immunosuppressants are on stable dose; AND
No rituximab or mitoxantrone in last 3 months; AND
No IVIG in last 3 weeks; AND
Patient will or has received meningococcal vaccine at least 2 weeks before treatment; AND
Site of care medical necessity is met

Patient has demonstrated positive clinical response (improvement or stabilization of neurologic symptoms, reduction in hospitalizations, or reduction/discontinuation in plasma exchange) according to prescriber; AND
Site of care medical necessity is met

initial 6 months; reauth 12 months