CurrentColorado Rocky Mountain Health PlansPolicy N/A

Florida Medicaid Prior Authorization — Exondys 51 (eteplirsen)

This document is the Florida Medicaid prior authorization form and instructions for requesting initiation or continuation of Exondys 51 (eteplirsen) for eligible beneficiaries; it governs what information providers must submit to request PA for this drug.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization form for Exondys 51 (eteplirsen)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed PA form with official genetic testing confirming diagnosis and required functional tests and labs; fax to 1-866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsmaximum approval length

5 yearsprovider must retain documentation

1-866-940-7328fax number to submit PA

1-800-310-6826Pharmacy PA Call Center

Coverage Criteria for Exondys 51 (eteplirsen)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization form for Exondys 51 (eteplirsen)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed PA form with official genetic testing confirming diagnosis and required functional tests and labs; fax to 1-866-940-7328.

SourceLink

On This Page

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PA submission requirements: Completed PA form indicating Initiation or Continuation of Therapy; official genetic testing confirming diagnosis must be provided; submit baseline and recent assessments including Six-Minute Walk Test, Brooke Upper Extremity Function Scale, and Forced Vital Capacity when available; include copies of medical records, diagnostic evaluations, chart notes, and most recent labs.

Maximum Length of Approval is 6 months; provider must retain documentation for five years.

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Initial Therapy

Initiation Therapy

For initiation requests

Initiation requirements: Indicate initiation on the form and submit official genetic testing confirming diagnosis plus baseline functional measures and labs. Incomplete forms may be returned.

Form completion: Form must be completed in full; missing information or missing official lab reports/testing may cause the PA to be returned or denied.

Fax completed form to 1-866-940-7328.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for both initiation and continuation of Exondys 51 (eteplirsen). Maximum approval length is 6 months. Submit the completed PA form and obtain prior authorization before dispensing.

Initiation and continuation of therapy require PA
Maximum approval period: 6 months

Denial Risk

Incomplete Submission May Be Returned or Denied

An incomplete prior authorization form or missing official laboratory reports/testing may result in the PA being returned or denied. Ensure all required fields on the form are completed.

Incomplete PA form may be returned or denied
Missing official lab reports/testing will impact decision

Documentation Required

Required Documentation

Required documentation must be submitted with the PA request: the completed PA form plus official genetic testing confirming the diagnosis, and relevant functional assessments and labs. The provider must retain copies of all documentation for five years.

Official genetic testing confirming diagnosis (indicate date of test)
Six-minute walk test (include date)
Brooke Upper Extremity Function Scale (include date)
Forced Vital Capacity (include date)
All relevant medical records, diagnostic evaluations, recent chart notes, and most recent labs
Fax completed PA and supporting documents to 1-866-940-7328

Note

Provider Submission Instructions

If prescribing, ensure prescriber information and signatures are provided, patient identifiers are complete, and the PA form is faxed to the PA fax number or submitted via the Pharmacy PA Call Center to avoid processing delays.

Include patient Medicaid ID and date of birth
Include prescriber name, NPI, phone, fax, and signature
Provide weight and diagnosis on the form
Fax to 1-866-940-7328 or contact Pharmacy PA Call Center at 1-800-310-6826

Definitions

inv-09: Official Genetic Testing Confirming Diagnosis — laboratory report documenting the diagnostic genetic test for the patient's condition.

DefinitionLaboratory report documenting the diagnostic genetic test for the patient's condition

Form fieldOfficial Genetic Testing Confirming Diagnosis: Yes/No with Date of Test

Submission requirementOfficial lab reports and testing must be submitted with the prior authorization request

Role in reviewRequired for review alongside medical records, functional tests, and most recent related labs

Background

The prior authorization form requests documentation to confirm diagnosis and to establish baseline and ongoing function for beneficiaries considered for Exondys 51 (eteplirsen). Providers must submit an official genetic test report confirming the diagnosis (include date of testing) plus clinical assessments such as the Six-Minute Walk Test, Brooke Upper Extremity Function Scale, and Forced Vital Capacity (FVC) when applicable. Also include copies of relevant medical records (diagnostic evaluations, recent chart notes), most recent related laboratories, and any other data needed to support initiation or continuation of therapy.

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