Description: Inj. inebilizumab-cdon, 1 mg
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 300mg IV followed by another 300mg IV 2 weeks later
• 300mg IV every 6 months
Calculate drug reimbursement
(ASP: $134,013.11, Margin: $8,040.79)
# Units to bill:300
Prior auth criteria for Uplizna may include but is not limited to:
1. The patient must have a confirmed diagnosis of neuromyelitis optica spectrum disorder (NMOSD) based on a positive AQP4-IgG serology test.
2. The patient must have had an inadequate response to at least two different disease-modifying treatments, including one treatment approved by the U.S. Food and Drug Administration (FDA) for NMOSD.
3. The patient must have experienced at least one episode of NMOSD-related vision loss or weakness in the past six months that required hospitalization or intravenous corticosteroids.
4. The patient must be 12 years of age or older.
5. The patient must not have any contraindications to Uplizna therapy, such as a history of hypersensitivity to albumin-containing products, or a history of severe allergic reactions to any components of Uplizna.
Insurance prior auth guidelines:
Uplizna (HORIZON THERAPEUTICS USA, INC.)