OH Epic Formulary, available via therapy plan, restricted to:

• Indication: treatment of generalized myasthenia gravis (gMG) in adult patients who are anti-acetylcholine receptor (AChR) or anti muscle-specific tyrosine kinase (MuSK) antibody positive
• Service line: Neurology
• Formulary location: Outpatient
• Service location: Outpatient infusion, Home infusion
• Patient population: Adult
• Prior authorization required: Yes
• Restriction/criteria of use (all will apply unless specified):
  • Documented diagnosis of gMG with confirmed positive record of autoantibodies against AChR or MuSK.
  • Patient has a Myasthenia Gravis Foundation of America (MGFA) Clinical Classification of class II, III, or IV disease at the start of therapy.
  • Patient has Myasthenia Gravis-Activities of Daily Living (MG-ADL) score ≥ 3.
  • Must not be used with other biologic therapies for myasthenia gravis or immunoglobulin therapy.
  • Trial and failure, contraindications or intolerance to at least one (1) immunosuppressive therapy (e.g., corticosteroids, methotrexate, azathioprine, cyclophosphamide, cyclosporine, mycophenolate mofetil, or tacrolimus).

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