Evrysdi — Blue Cross Blue Shield of New Mexico

spinal muscular atrophy (SMA) types 1, 2, or 3

Initial criteria

Diagnosis of spinal muscular atrophy (SMA)
Deletion or mutation at the survival motor neuron 1 (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: (A) If symptomatic, symptom onset was evident prior to 18 years of age OR (B) If asymptomatic, patient has no more than 4 copies of SMN2
At least ONE baseline functional assessment based on age and motor ability: CHOP-INTEND OR HINE-2 OR HFMSE OR 6MWT OR BSID OR MFM32 OR RULM
Patient does NOT require invasive ventilation or tracheostomy
Patient has NOT received gene therapy for the requested indication (e.g., Zolgensma [onasemnogene abeparvovec-xioi])
If the patient has used Spinraza (nusinersen) in the last four months, they will complete a 4-month washout period between last Spinraza dose and initiation of requested agent
Patient will NOT use requested agent in combination with Spinraza (nusinersen)
Prescriber is a neurologist, geneticist, or has consulted with a specialist in the area of the patient’s diagnosis
Patient does NOT have any FDA labeled contraindications to the requested agent

Patient previously approved for the requested agent through plan’s prior authorization process
Patient has improvements or stabilization from baseline with therapy as indicated by one of the following assessments: 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 the requested indication (e.g., Zolgensma)
Patient will NOT be using the requested agent in combination with Spinraza (nusinersen)
Prescriber is a neurologist, geneticist, or has consulted with a specialist in the area of the patient’s diagnosis
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months