CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Zolgensma (onasemnogene abeparvovec-xioi) — Intravenous therapy coverage criteria

Policy governing single-dose coverage, dosing, and medical necessity criteria for intravenous Zolgensma for pediatric patients with spinal muscular atrophy (SMA) under Neighborhood Health Plan of Rhode Island (Medicaid, Commercial, MMP).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyZolgensma (onasemnogene abeparvovec-xioi) — Intravenous therapy coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 14, 2019

Next Review DateN/A

Key ActionSubmit prior authorization with medical records including genetic testing, baseline labs, baseline anti-AAV9 titer, and most recent CHOP INTEND score.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one lifetime doselength of authorization

<2 yrsmaximum patient age for eligibility

CHOP ≥40required baseline motor score

anti-AAV9 ≤1:50required baseline antibody titer

2.6–21.0 kgallowed patient weight range

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