Coverage of Spinraza (nusinersen) and Exondys 51 (eteplirsen)
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Requirements and prior authorization routing for Spinraza (nusinersen) and Exondys 51 (eteplirsen) for Simply Healthcare Plans, Inc. and Clear Health Alliance members, including submission instructions and where additional criteria can be found. Affects providers requesting prior authorization for these medications.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior authorization is required for Spinraza (nusinersen) and Exondys 51 (eteplirsen). Fax all prior authorization requests, with a completed Prior Authorization Form for Medical Injectables, to the Simply Medical Injectables department at 1-844-509-9862. The form is available on the provider websites at www.simplyhealthcareplans.com/provider or www.clearhealthalliance.com/provider.
Do not send prior authorization requests for these medications to the Agency for review; routing to the Agency is no longer used for Simply Healthcare Plans and Clear Health Alliance members. For questions or assistance, contact your local Provider Relations representative or call Provider Services toll free at 1-844-405-4296.
Coding
| No codes listed |
Provider Actions & Prior Authorization
Prior authorization required for Spinraza® and Exondys 51™
Prior authorization is required for Spinraza® (nusinersen) and Exondys 51™ (eteplirsen). Submit a completed Prior Authorization Form for Medical Injectables and fax the request to the Simply Medical Injectables department for review.
Include form, documentation, and use provided support channels
Ensure the Prior Authorization Form for Medical Injectables accompanies clinical documentation and that requests are routed to the Simply Medical Injectables department; contact Provider Services or your local Provider Relations representative for assistance if needed.
Required form and fax submission details
Use the Prior Authorization Form for Medical Injectables (available on the Simply provider websites) and fax prior authorization requests for Spinraza and Exondys 51 to 1-844-509-9862; the form must accompany the request.
- Form available at www.simplyhealthcareplans.com/provider or www.clearhealthalliance.com/provider
- Fax number: 1-844-509-9862
Route prior authorization requests to Simply Medical Injectables or risk denial
Failure to fax prior authorization requests for Spinraza and Exondys 51 to the Simply Medical Injectables department at 1-844-509-9862 may result in lack of routing for review and potential denial of coverage.
- Do not send these requests to the Agency; they should be sent directly to the Simply Medical Injectables department.
- If you need assistance, contact your local Provider Relations representative or Provider Services at 1-844-405-4296.
Definitions
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