Prior Authorization Form: Antisense oligonucleotides for Duchenne muscular dystrophy
Prior authorization form and requirements for coverage of antisense oligonucleotide exon‑skipping therapies for members with Duchenne muscular dystrophy under Anthem HealthKeepers Medicaid products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Initial coverage for all medications will be approved when ALL of the following are met:
All three conditions must be checked 'Yes' on the form and prescriber must sign and date the form.
Continuation/Renewal Therapy
Renewal coverage for all medications will be approved when ALL of the following are met:
Prescriber must attest (checkboxes) and sign/date the form; attach monitoring documentation as appropriate.
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