Notification of Drug Policy Revisions Effective December 1, 2024 (Posted October 1, 2024)

Medical Drug Policy Name	Revised Criteria
Eculizumab (Soliris®) Notification (PDF)	For NMOSD indication, added requirement for trial and failure of ravulizumab (Ultomiris®) to existing required trial and failure of Uplizna® and Enspryng™. Updated requirement within initial and continuation sections that Soliris will not be used in combination with ravulizumab for clarity. For PNH indication, updated requirement within initial and continuation sections that Soliris will not be used in combination with newly approved crovalimab for clarity. For gMG indication, added requirement within initial and continuation sections for clarity that Soliris will not be used in combination with the following products: rozanolixizumab, ravulizumab, efgartigimod alfa/efgartigimod alfa and hyaluronidase, and zilucoplan. Formatting changes made throughout FDA label reference table for clarity with no change to policy intent. Policy notification given 10/1/2024 for effective date 12/1/2024.

Medical Drug Policy Name

Revised Criteria

Eculizumab (Soliris®) Notification (PDF)

For NMOSD indication, added requirement for trial and failure of ravulizumab (Ultomiris®) to existing required trial and failure of Uplizna® and Enspryng™. Updated requirement within initial and continuation sections that Soliris will not be used in combination with ravulizumab for clarity. For PNH indication, updated requirement within initial and continuation sections that Soliris will not be used in combination with newly approved crovalimab for clarity. For gMG indication, added requirement within initial and continuation sections for clarity that Soliris will not be used in combination with the following products: rozanolixizumab, ravulizumab, efgartigimod alfa/efgartigimod alfa and hyaluronidase, and zilucoplan. Formatting changes made throughout FDA label reference table for clarity with no change to policy intent. Policy notification given 10/1/2024 for effective date 12/1/2024.

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