Formulary restrictions:

• Indication: Treatment of neuromyelitis optica spectrum disorder (NMOSD) seropositive for aquaporin-4 (AQP4) IgG antibodies
• Service Line: Neurology, Immunology, Hematology
• Formulary location: Outpatient infusion
• Service Location: Outpatient infusion centers, Home infusion
• Patient population: Adults
• Prior Authorization Required: yes
• Criteria of Use/Restriction:
  • Seropositive for aquaporin-4 (AQP4) IgG antibodies
  • Tried and failed therapy with rituximab or other therapies (e.g., azathioprine or mycophenolate), prior to Uplizna
  • EDSS score of 8 or less (The EDSS ranges from 1 to 10 in units of 0.5, with higher numbers indicating worsening disability)
  • Women of child-bearing potential should have a negative urine pregnancy test prior to initiation of therapy and repeat pregnancy testing prior to 6-month dosing and should be on birth control while on Uplizna
  • Negative TB result prior to initiation of therapy (on either chest radiograph or by QuantiFERON gold test); contraindicated if active or untreated latent TB
  • Negative hepatitis B serology prior to initiation of therapy; contraindicated if active hepatitis B infection

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