CurrentUnitedHealthcarePolicy CSNJ2025D0086L

Vyondys 53 (Golodirsen) (for New Jersey Only) - Medical Benefit Drug Policy

State-specific (New Jersey) UnitedHealthcare medical benefit drug policy that defines coverage criteria, initial and continuation authorization requirements, applicable codes, and clinical evidence for Vyondys 53 (golodirsen).

Policy Summary

PayerUnitedHealthcare

PolicyMedical Benefit Drug Policy — Vyondys 53 (golodirsen) (for New Jersey Only)

Policy CodePolicy CSNJ2025D0086L

Change TypeRevised coverage criteria

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders must submit medical records confirming diagnosis, mutation amenable to exon 53 skipping, baseline functional status, and (if applicable) documentation of prior gene therapy and subsequent clinically meaningful decline; initial and reauthorizations limited to no more than 12 months.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for initial therapy to add requirement that one of the following is met: patient has not previously received gene therapy for DMD OR if previously received gene therapy, submission of records documenting clinically meaningful functional decline since gene replacement therapy.

1HCPCS drug code listed

1Diagnosis code listed

12 moInitial authorization limit

12 mo

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