Provider Alert! Amondys 45 Becomes a Benefit for Medicaid and CHIP

Provider Alert!

Provider Alert! Amondys 45 Becomes a Benefit for Medicaid and CHIP

Attention: Neurologists

Effective Date: June 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan would like to inform providers of a new benefit effective June 1, 2021. The Health and Human Services Commission (HHSC) will cover Amondys 45 under HCPCS code J3490 from June 1 until June 30, 2021. Beginning July 1, 2021, HHSC will cover Amondys 45 under CMS-issued HCPCS code C9075. Amondys 45 is indicated to treat Duchenne Muscular Dystrophy (DMD) in individuals who have a confirmed mutation of the DMD gene that is amenable to exon 45 skipping.

How this impacts providers: Prior authorization guidance for Amondys 45 is as follows.
An initial request for Amondys 45 (Casimersen) must include the following documentation to support medical necessity:

  • Genetic testing must confirm that the client’s DMD gene is amenable to exon 45
  • Serum cystatin C, urine dipstick, and urine protein-to-creatinine ratio should be measured prior to initiating therapy.
  • Baseline renal function test (i.e., Glomerulus Filtration Rate) and urine protein-to-creatinine ratio should be measured before starting treatment.
  • Current client weight, including the date the weight was obtained; the weight must be dated no more than 30 days before the request date.

Available testing tools to demonstrate physical function include, but are not limited to:

  • Brooke Upper Extremity Scale.
  • Baseline 6MWT (6-minute walk test).
  • North Star Ambulatory Assessment.

Amondys 45 should not be used concomitantly with other exon-skipping therapies for DMD.

A recertification/extension request for Amondys 45 must include documentation of the following:

  • Continual renal function monitoring while on Amondys 45 therapy.
    • The client’s current weight and the date on which the weight was obtained. The weight must be dated no more than 30 days before the request date.

Amondys 45 should not be continued as a treatment for clients who experience decreasing physical function while on the medication.

Next steps for providers: Providers should share this communication with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

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