Evrysdi — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis of spinal muscular atrophy (SMA)
• Deletion or mutation at SMN1 gene on chromosome 5q confirmed by genetic testing (medical records required)
• Diagnosis of probable SMA Type 1, 2, or 3 AND ONE of the following: symptomatic with onset before age 18 years OR asymptomatic with no more than 4 copies of SMN2
• At least one baseline functional assessment (CHOP-INTEND, HINE-2, HFMSE, 6MWT, BSID, MFM32, or RULM)
• Patient does NOT require invasive ventilation or tracheostomy
• Patient has NOT received gene therapy for SMA (e.g., Zolgensma [onasemnogene abeparvovec-xioi])
• If patient has used Spinraza (nusinersen) in last four months, a four-month washout period must be completed prior to initiating requested agent
• Requested agent will NOT be used in combination with Spinraza (nusinersen)
• Prescriber is a neurologist, geneticist, or has consulted with such a specialist
• No FDA labeled contraindications to requested agent

Reauthorization criteria

• Previously approved for requested agent through the plan’s prior authorization process
• Improvement or stabilization from baseline with requested agent as demonstrated by one of the functional assessments (CHOP-INTEND, HINE-2, HFMSE, 6MWT, BSID, MFM32, RULM)
• Patient does NOT require invasive ventilation or tracheostomy
• Patient has NOT received gene therapy for SMA (e.g., Zolgensma [onasemnogene abeparvovec-xioi])
• Patient will NOT use requested agent in combination with Spinraza (nusinersen)
• Prescriber is a specialist (neurologist, geneticist) or has consulted with one
• No FDA labeled contraindications

Approval duration

12 months