CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNulibry (fosdenopterin) intravenous therapy for MoCD Type A

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2021

Next Review Date

Key ActionRequests must document diagnosis confirmation (molecular genetic testing) or biochemical features and baseline urinary SSC normalized to creatinine, clinical signs/symptoms, and specialist involvement; initial approvals are for 6 months (or 3 months if diagnosis unconfirmed one time only).

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Primary covered indication (MoCD Type A)

95 mgDaily max dose

6 moInitial authorization length

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.