Pharmacy Prior Authorization Criteria

Uplizna (inebilizumab-cdon)

Indications for Prior Authorization

Uplizna (inebilizumab-cdon)

• For diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD)
  Indicated for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in adult patients who are anti-aquaporin-4 (AQP4) antibody positive.

Criteria

Uplizna

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of neuromyelitis optica spectrum disorder (NMOSD)
AND
• Patient is anti-aquaporin-4 (AQP4) antibody positive
AND
• Prescribed by or in consultation with one of the following:
• Neurologist
• Ophthalmologist
AND
• One of the following:
• Trial and failure, contraindication, or intolerance to rituximab
OR
• For continuation of prior therapy

Uplizna

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-06-05, 2023-10-26, 2023-06-07, 2022-06-02, 2021-06-03, 2021-01-06, 2020-07-29

References

1. Uplizna Prescribing Information. Horizon Therapeutics USA, Inc. Deerfield, IL. July 2021.

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Revision History

• 2024-06-05: Annual review: Background and formatting updates.
• 2023-10-26: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-06-07: Annual review: No updates required.
• 2022-06-02: Annual review: Updated background.
• 2021-06-03: Annual review: Background updates.
• 2021-01-06: Updated prescriber requirement and added embedded step.
• 2020-07-29: New program

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