Pharmacy Prior Authorization Criteria

Yartemlea (narsoplimab-wuug) - PA, NF

Indications for Prior Authorization

Yartemlea (narsoplimab)

• For diagnosis of Hematopoietic Stem Cell Transplant-associated Thrombotic Microangiopathy (TA-TMA)
  Indicated for the treatment of adult and pediatric patients 2 years of age and older with hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA).

Criteria

Yartemlea

Prior Authorization

Length of Approval: 16 Week(s) [1]

• Diagnosis of hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA)
AND
• Patient is 2 years of age or older
AND
• Prescribed by a physician on the patient’s transplant care team

Yartemlea

Non Formulary

Length of Approval: OptumRx: 16 Week(s) [1], OptumRx-EHB: 12 Months

• Submission of medical records (e.g., chart notes) confirming diagnosis of hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA)
AND
• Patient is 2 years of age or older
AND
• Prescribed by a physician on the patient’s transplant care team

P & T Revisions

2026-06-26, 2026-03-05

References

1. Yartemlea Prescribing Information. Omeros Corporation. Seattle, WA. December 2025.
2. Consult with hematologist/oncologist on February 27, 2026.

---

Revision History

• 2026-06-26: Addition of Yartemlea NF criteria
• 2026-03-05: New Program

---