Nulibry (fosdenopterin) intravenous therapy for MoCD Type A
Policy governs coverage, authorization length, dosing, renewal, diagnosis and testing requirements, billing codes, and units for Nulibry (fosdenopterin) for Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island.
No material clinical/coverage changes
Coverage Summary
Scope: This policy governs coverage, authorization length, dosing, renewal, diagnosis and testing requirements, billing codes, and units for Nulibry (fosdenopterin) administered intravenously for Medicaid, Commercial, and Medicare members. Coverage stance: covered with criteria for the primary indication of MoCD Type A (Molybdenum cofactor deficiency Type A). The policy requires molecular genetic confirmation or supportive biochemical features, baseline urinary SSC normalized to creatinine, specialist involvement, and other specified documentation. Effective date: 07/01/2021. Last review: 05/01/2025. Nulibry is covered for MoCD Type A when the listed criteria are met.
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