CurrentColorado Rocky Mountain Health PlansPolicy N/A

Immunomodulators: Enspryng (North Carolina) Prior Authorization Form - Community Planopen_in_new

Provider-facing prior authorization form to request coverage of Enspryng for a beneficiary with NMOSD. Captures beneficiary, prescriber, drug details and specific clinical checklist items required for authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyImmunomodulators: Enspryng (North Carolina) Prior Authorization Form - Community Planopen_in_new

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must complete and submit the prior authorization form including beneficiary demographics, prescriber NPI, drug name/strength/quantity/length of therapy, and answer the NMOSD clinical checklist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

7Required checklist items

Coverage Summary

Provider-facing prior authorization form to request coverage of Enspryng (satralizumab) for a beneficiary with Neuromyelitis Optica Spectrum Disorder (NMOSD); coverage stance = covered_with_criteria. The form captures beneficiary demographics, prescriber NPI and contact, drug name/strength/quantity per 30 days and length of therapy, and a clinical checklist of required items for authorization including diagnosis, AQP4 antibody positive status, age (≥18), confirmation the patient is not on another injectable biologic immunomodulator, screening for latent tuberculosis, Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab) testing, and prescriber signature certifying accuracy.

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Authorization Criteria

Authorization Criteria for Enspryng (NMOSD)

Coverage is requested and would be considered when ALL of the following are met:

Diagnosis: Beneficiary has a diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD).
AQP4 Antibody Status: Beneficiary is anti-aquaporin-4 (AQP4) antibody positive.
Age: Beneficiary is 18 years of age or older.
Concomitant Therapy: Beneficiary is not on another injectable biologic immunomodulator.
Tuberculosis Screening: Beneficiary has been considered and screened for the presence of latent tuberculosis infection.
Screening must be considered/screened prior to initiating therapy.
Hepatitis B Testing: Beneficiary has been tested for Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab).
Prescriber Signature: Prescriber signature is provided certifying accuracy and completeness of information.
Prescriber signature is mandatory.

Provider Actions / Prior Authorization

Prior Authorization

Submit prior authorization request

Prescriber must complete and submit the prior authorization form including beneficiary demographics, prescriber NPI, drug name/strength/quantity/length of therapy, and answer the NMOSD clinical checklist.

Documentation Required

Clinical documentation required

Document diagnosis of NMOSD, AQP4 antibody positive status, age 18 or older, that the patient is not on another injectable biologic immunomodulator, consideration/screening for latent tuberculosis, and Hepatitis B surface antigen and core antibody test results.

Billing Rule

Specify drug administration duration and quantity

Form requests Quantity Per 30 Days and Length of Therapy (options up to 30 days through 365 days); provider must specify these fields on the form.

Background

This prior authorization form is used by Colorado Rocky Mountain Health Plans to collect necessary beneficiary, prescriber, and clinical information to authorize Enspryng (satralizumab) for treatment of NMOSD in adults who are AQP4 antibody positive. The form requires documentation that the beneficiary has NMOSD, is ≥18 years old, is not receiving another injectable biologic immunomodulator, and that the beneficiary has been considered/screened for latent tuberculosis and tested for Hep B SAG and Core Ab prior to initiating therapy. Prescriber signature is mandatory to certify accuracy and completeness.

Definitions: AQP4 = Anti-aquaporin-4 antibody; Hep B SAG = Hepatitis B surface antigen; Core Ab = Hepatitis B core antibody.

Revision History

coverage_criteriaLatest

Coverage is requested when all criteria are met: diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD); anti-aquaporin-4 (AQP4) antibody positive; age 18 years or older; not on another injectable biologic immunomodulator; beneficiary considered/screened for latent tuberculosis infection; tested for Hepatitis B surface antigen (Hep B SAG) and Hepatitis B core antibody (Core Ab); prescriber signature certifying accuracy and completeness of information. Prior authorization form must include beneficiary demographics, prescriber NPI, drug name/strength/quantity per 30 days, and length of therapy.