Criteria for Prior Authorization: Neuromyelitis Optica Spectrum Disorder (NMOSD) Agents
Customize your policy alerts
Sign up for all Kansas Department of Health and Environment policy alerts
Know when Kansas Department of Health and Environment releases new policies or updates existing guidance.
Monitor payer policy activity
Defines prior authorization requirements for neuromyelitis optica spectrum disorder (NMOSD) medications for members whose drug benefits are managed by the Kansas Department of Health and Environment; covers initial and renewal criteria, approved agents, age and dosing limits, and documentation requirements for prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met
Based on General Criteria for Initial Prior Authorization.
Renewal Therapy
Covered for renewal when ALL of the following are met
Based on Criteria for Renewal Prior Authorization.
Concurrent therapy with another NMOSD agent listed in Table 1 is not permitted. This applies to all requests for initial or renewal prior authorization; the provider must attest that the patient is not receiving any other agent from Table 1 at the time of initiation or renewal.
Approved Agents, Dosing, and Coding
| Eculizumab (Soliris®) | NMOSD; AQP4 antibody positive; Age = ≥ 18 years; Dosing: 900 mg IV weekly for the first 4 weeks, then 1200 mg IV week 5, then 1200 mg IV every 2 weeks. |
| Ravulizumab-cwvz (Ultomiris®) | NMOSD; AQP4 antibody positive; Age = ≥ 18 years; Dosing: weight-based per Table 1 (examples: 40 to <60kg induction: 2,400 mg IV x1; maintenance starting 2 weeks after induction: 3,000 mg IV every 8 weeks; additional weight-based dosing for 60 to <100kg and ≥100kg noted in Table 1). |
| Inebilizumab-cdon (Uplizna™) | NMOSD; AQP4 antibody positive; Age = ≥ 18 years; Dosing: 300 mg IV, followed by a second 300 mg IV 2 weeks later, then 300 mg IV every 6 months. |
| Satralizumab-mwge (Enspryng®) | NMOSD; AQP4 antibody positive; Age = ≥ 18 years; Dosing: 120 mg SQ at weeks 0, 2 and 4, followed by 120 mg SQ every 4 weeks. |
Provider Actions and Documentation Requirements
Prior authorization required for listed NMOSD agents
Prior authorization is required for all current and future dose forms of the NMOSD agents listed in Table 1; medication-specific criteria including drug-specific indication, age, and dosing limits in Table 1 must be met.
Preferred PDL drug required unless non-preferred criteria met
The preferred PDL drug that treats the PA indication is required unless the patient meets the non-preferred PDL prior authorization criteria.
Documentation required for initial prior authorization
For initial prior authorization, the prescriber must provide the patient’s baseline number of relapses in the 12 months before treatment and confirm the patient has a positive AQP4‑IgG serologic test (cell‑based assay) and at least one core clinical characteristic from Table 2.
- Baseline number of relapses in the past 12 months prior to initiation
- Positive serologic test for AQP4‑IgG (cell‑based assay)
- At least one core clinical characteristic listed in Table 2
Documentation required for renewal prior authorization
For renewal prior authorization, the provider must attest the patient is not on concurrent therapy with another NMOSD agent listed in Table 1 and document that the patient has had a decrease or no increase in clinical relapses in the most recent 12 months after starting the requested agent.
- Attestation that patient is not receiving concurrent NMOSD therapy from Table 1
- Documentation showing decrease or no increase in clinical relapses in the most recent 12 months
Denial triggers for initial prior authorization
Failure to meet all general criteria for initial prior authorization — including approved indication/age/dosing per Table 1, use of preferred PDL when applicable, neurologist prescribing/consultation, documented AQP4‑IgG positivity, absence of concurrent listed NMOSD therapy, and submission of baseline relapse count — may result in denial.
- Not approved for the requested indication, age, or exceeds Table 1 dosing limits
- Preferred PDL drug not used without meeting non‑preferred criteria
- No documentation of neurologist prescribing or consultation
- Missing positive AQP4‑IgG cell‑based assay
- Concurrent therapy with another NMOSD agent listed in Table 1
- No baseline relapse count provided for the prior 12 months
Denial triggers for renewal prior authorization
For renewals, lack of documentation demonstrating a decrease or no increase in clinical relapses in the most recent 12 months after treatment initiation, or dosing that exceeds the limits in Table 1, may result in denial.
- No documentation of decreased or stable relapse frequency in the most recent 12 months
- Dosing that exceeds Table 1 limits
Background
Neuromyelitis optica spectrum disorder (NMOSD) is managed with targeted agents for patients with AQP4‑IgG positivity. Diagnosis for PA purposes requires a clinical diagnosis of NMOSD with at least one core clinical characteristic from Table 2 (for example, optic neuritis, acute myelitis, area postrema syndrome, or other NMOSD‑typical brain/brainstem/diencephalic presentations) AND a positive AQP4‑IgG cell‑based assay. Prescribers must confirm serologic AQP4‑IgG positivity and document the patient’s baseline relapse history when initiating therapy.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.