Pharmacy Prior Authorization Criteria

Mepsevii (vestronidase alfa-vjbk)

Indications for Prior Authorization

Mepsevii (vestronidase alfa-vjbk)

• For diagnosis of Mucopolysaccharidosis (MPS VII, Sly Syndrome)
  Indicated for the treatment of Mucopolysaccharidosis (MPS VII, Sly Syndrome) in pediatric and adult patients.

  Limitations of use: The effect of Mepsevii on the central nervous system manifestations of MPS VII has not been determined.

Criteria

Mepsevii

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Mucopolysaccharidosis (MPS VII, Sly Syndrome)

• Diagnosis of Mucopolysaccharidosis VII (MPS VII, Sly syndrome)

Mepsevii

Prior Authorization (Reauthorization)

Length of Approval: 24 Month(s)
For diagnosis of Mucopolysaccharidosis (MPS VII, Sly Syndrome)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-04-26, 2023-10-03, 2023-05-03, 2022-03-28, 2021-09-27, 2021-05-20, 2020-05-14

References

1. Mepsevii Prescribing Information. Ultragenyx Pharmaceutical Inc. Novato CA. December 2020.

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Revision History

• 2024-04-26: Annual review: No criteria changes.
• 2023-10-03: Program update to standard reauthorization language. No changes to clinical intent
• 2023-05-03: Annual review: Initial authorization approval duration updated to 12 months. New reauthorization section added.
• 2022-03-28: 2022 Annual Review - No changes to criteria
• 2021-09-27: Annual review
• 2021-05-20: Annual review
• 2020-05-14: Annual Review - No Changes

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