Pharmacy Prior Authorization Criteria

Enspryng (satralizumab-mwge)

Indications for Prior Authorization

Enspryng (satralizumab-mwge)

• For diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD)
  Indicated for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

Criteria

Enspryng

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of neuromyelitis optica spectrum disorder (NMOSD)
AND
• Patient is anti-aquaporin-4 (AQP4) antibody positive
AND
• Prescribed by or in consultation with one of the following:
• Neurologist
• Ophthalmologist
AND
• One of the following:
• Trial and failure, contraindication, or intolerance to rituximab
OR
• For continuation of prior Enspryng therapy

Enspryng

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-09-26, 2023-10-30, 2023-10-04, 2022-10-05, 2021-10-06, 2021-01-06, 2020-10-07

References

1. Enspryng Prescribing Information. Genentech, Inc. South San Francisco, CA. March 2022.

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Revision History

• 2024-09-26: 2024 UM Annual Review. No changes
• 2023-10-30: Updated reauth language
• 2023-10-04: Annual review: No updates required.
• 2022-10-05: Annual review: Background updates.
• 2021-10-06: Annual review: Background updates.
• 2021-01-06: Updated prescriber requirement and added embedded step.
• 2020-10-07: New program

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