Aqneursa (levacetylleucine) — United Healthcare
Treatment of neurological manifestations of Niemann-Pick disease type C (NPC)
Preferred products
- miglustat
Initial criteria
- Diagnosis of Niemann-Pick disease type C (NPC)
- Diagnosis has been genetically confirmed by mutation analysis of NPC1 and NPC2 genes
- Aqneursa is being used to treat neurological manifestations of NPC
- Aqneursa is prescribed in combination with miglustat OR history of failure, contraindication, or intolerance to miglustat
- Patient is not receiving Aqneursa in combination with Miplyffa (arimoclomol)
- Aqneursa is prescribed by or in consultation with a provider with expertise in the treatment of NPC
Reauthorization criteria
- Documentation of positive clinical response to Aqneursa therapy (e.g., slowed disease progression from baseline based on assessment with NPC–specific scales)
- Aqneursa is prescribed in combination with miglustat OR history of failure, contraindication, or intolerance to miglustat
- Patient is not receiving Aqneursa in combination with Miplyffa (arimoclomol)
- Aqneursa is prescribed by or in consultation with a provider with expertise in the treatment of NPC
Approval duration
12 months