CurrentCignaPolicy N/A

Enspryng (sartralizumab) prior authorization for NMOSD

This form governs prior authorization requirements for prescribing Enspryng (sartralizumab-mwge) for neuromyelitis optica spectrum disorder (NMOSD) to Cigna members; it affects prescribers, dispensing facilities, and specialty pharmacies submitting requests.

Policy Summary

PayerCigna

PolicyEnspryng (sartralizumab) prior authorization for NMOSD

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Enspryng prior authorization form with required clinical details (AQP4 antibody status, relapse history, prior therapies) and attach supportive documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

AccredoCigna's nationally preferred specialty pharmacy

NMOSDspecified diagnosis related to use

Coverage and Medical Necessity

Information required to evaluate medical necessity

Prior authorization will be considered when the following information is provided on the form:

Form completion and documentation: All required patient and provider identifiers (asterisked items) are completed and supportive documentation (chart notes, lab/test results) is attached.

See patient information and clinical information sections

Indication: Diagnosis listed as neuromyelitis optica spectrum disorder (NMOSD) or other specified indication; if NMOSD, indicate AQP4 antibody test result.

AQP4 antibody positive status asked on form

Prior therapy or contraindication documentation: Documentation of prior use of Soliris or Uplizna, azathioprine, corticosteroids, mycophenolate, rituximab, or reasons why alternatives cannot be used (intolerance, contraindication, formulation issues).

Policy Summary

PayerCigna

PolicyEnspryng (sartralizumab) prior authorization for NMOSD

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Enspryng prior authorization form with required clinical details (AQP4 antibody status, relapse history, prior therapies) and attach supportive documentation.

SourceLink

On This Page

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Requests lacking required clinical details risk denial. The form requires attachment of supportive documentation (chart notes, lab/test results) for all answers and specifically asks for the patient’s AQP4 antibody testing status (positive vs. negative) when NMOSD is the diagnosis, documentation of prior therapies tried (including dates, doses, duration, and reasons for discontinuation or intolerance), and a description of relapse history. The form also asks whether Enspryng is prescribed by or in consultation with a neurologist. Omitting any of these elements — AQP4 status, relapse/prior-relapse details, or prior therapy documentation — may result in inability to approve the request.

What Providers Must Provide / Action Items

Prior Authorization

Prior Authorization Required

Prior authorization required. Complete and submit the Enspryng prior authorization form with all requested fields. The form must include indication, medication requested (Enspryng 120 mg/ml syringe), dose, quantity, duration, and whether this is a new start or continuation of therapy. Requests submitted without a completed PA form will be delayed or denied.

Medication: Enspryng 120 mg/ml syringe
Specify dose, quantity, duration, and new start vs continuation
Submit via CoverMyMeds or SureScripts or fax with all required asterisked fields completed

Documentation Required

Supportive Documentation Required — Attach Charts and Labs

Supportive clinical documentation (chart notes, clinic visit notes, lab/test results) must be attached to the PA request. The request explicitly requires supportive documentation for all answered clinical questions. Failure to attach chart notes and lab results may result in denial for lack of medical documentation.

Attach chart notes documenting diagnosis, history of relapses, and response to prior therapies
Attach lab results confirming anti-aquaporin-4 (AQP4) antibody status when NMOSD is indicated
Include documentation of neurologist involvement or consultation when applicable

Denial Risk

Incomplete Clinical Criteria — Risk of Denial if Missing

Incomplete clinical criteria on the PA form increases risk of denial. Ensure the form documents: confirmation of AQP4 antibody status when NMOSD is claimed; history of relapses (≥1 in last 12 months or ≥2 in last 2 years, if applicable); whether a neurologist is prescribing or consulted; and clinical benefit if requesting continuation therapy.

If continuation, document objective beneficial response (e.g., reduced relapse rate, improved symptoms)
Document relapse history with dates and clinical notes
Indicate neurologist involvement or consultation

Documentation Required

Required Documentation and Identifiers

The PA form requires specific patient and provider identifiers and attachments. Complete all asterisked patient fields and provider identifiers to avoid processing delays.

Required patient identifiers: Cigna ID, patient name, date of birth, address, phone
Required provider identifiers: Physician name, specialty, DEA, NPI or TIN, office contact, phone, fax, office address
Prescriber signature and date required on form

Step Therapy

Step Therapy / Alternative Therapy Documentation

Step-therapy and alternative therapy information must be provided. The form asks whether the patient has tried Soliris or Uplizna and documents prior trials of immunosuppressants (azathioprine, corticosteroids, mycophenolate mofetil, rituximab) including dates, durations, outcomes, and intolerances. If alternatives were not tried, indicate why the patient cannot use them (contraindication, intolerance, formulation need, disease characteristic, or other).

State whether patient previously tried Soliris or Uplizna
For each alternative (azathioprine, corticosteroid, mycophenolate, rituximab) provide trial dates, duration, and documented lack of efficacy or intolerance
If alternatives not tried, document reason (contraindication, intolerance, formulation, clinical rationale)

Key Definitions

AQP4 antibody positive — definition

DefinitionPositive blood serum test for anti-aquaporin-4 (AQP4) antibody

Documentation required on formForm asks: 'Has the diagnosis been confirmed by a positive blood serum test for anti-aquaporin-4 antibody? (Yes/No)'

Supportive evidence to attachAttach chart notes and lab/test results demonstrating AQP4 antibody positive serum test

NMOSD — listed indication

TermNeuromyelitis optica spectrum disorder (NMOSD)

Form usageDiagnosis related to use listed on form as 'neuromyelitis optica spectrum disorder (NMOSD)'

Clinical follow-upIf NMOSD is selected, form requests confirmation of AQP4 antibody testing and relapse/prior therapy history

OpenPayer

Enspryng (sartralizumab) prior authorization for NMOSD

Coverage and Medical Necessity

Drug and Procedure Coding

What Providers Must Provide / Action Items

Clinical Background

Key Definitions