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: [A]
• 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

2025-09-17, 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. September 2022.
2. Kumpfel T, Giglhuber K, Aktas O, et al. Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders (NMOSD) – revised recommendations of the Neuromyelitis Optica Study Group (NEMOS). Part II: Attack therapy and long-term management. J Neurol. 2024 Jan; 271(1):141-176.

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End Notes

1. A. Both Enspryng and rituximab have demonstrated efficacy in AQp4-IgG-positive NMOSD, but data from Enspryng trials for treatment initiation (“first-line” terapy) after diagnosis is more limited. [2]

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Revision History

• 2025-09-17: 2025 Annual Review - No criteria changes. Background updates.
• 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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