Table 3.
Payer coverage criteria for nusinersen for spinal muscular atrophy
| Plan imposes additional coverage criteria | Covered types of SMA | Required number of copies of SMN2 gene | Age requirement at treatment initiation | Ventilation requirements* | Motor function requirements | Prescriber requirement | |
|---|---|---|---|---|---|---|---|
| Plan 1 | Yes | 1, 2, or 3 | NA | ≤ 15 years | Patient is not ventilator dependent* | NA | Neurologist with expertise in SMA |
| Plan 2 | Yes | NA | 1 or 2 copies | NA | NA | NA | NA |
| Plan 3 | Yes | 1, 2, or 3 | NA | NA | NA | NA | Neurologist |
| Plan 4 | Yes | NA | NA | NA | NA | NA | Neurologist |
| Plan 5 | Yes | 1, 2, or 3 | NA | ≤ 14 years | Patient is not ventilator dependent* | NA | Neurologist with expertise in SMA |
| Plan 6 | Yes | NA | ≥ 2 copies | NA | NA | NA | Neurologist |
| Plan 7 | Yes | 1, 2, or 3 | NA | NA | NA | Member retains meaningful voluntary motor function† | NA |
| Plan 8 | Yes | 1, 2, or 3 | 1, 2, or 3 copies | NA | NA | Member retains meaningful voluntary motor function† | NA |
| Plan 9 | Yes | 1, 2, or 3 | NA | NA | Not dependent for > 6 h a day | NA | Neurologist with expertise in SMA |
| Plan 10 | Yes | 1, 2, or 3 | 1, 2, 3, or 4 copies | NA | Patient is not ventilator dependent* | NA | NA |
| Plan 11 | Yes | 1, 2, or 3 | NA | ≤ 15 years | Patient is not ventilator dependent* | Member retains meaningful voluntary motor function† | Neurologist |
| Plan 12 | Yes | 1, 2, or 3 | 1 or 2 copies | ≤ 15 years | Not dependent for > 12 h a day | NA | Neurologist with expertise in SMA |
| Plan 13 | No policy | 1, 2, or 3 | NA | ≤ 15 years | NA | NA | NA |
| Plan 14 | Yes | 1, 2, or 3 |
Symptomatic patients: 2, 3, or 4 copies; Asymptomatic patients: 2 or 3 copies |
≤ 15 years | Patient is not ventilator dependent* | NA | Neurologist with expertise in SMA |
| Plan 15 | Yes | NA | Early onset: 1 or 2 copies; Late onset: 1, 2, or 3 copies | NA | NA | NA | NA |
| Plan 16 | Yes | 1, 2, or 3 | NA | NA | NA | NA | Neurologist |
| Plan 17 | Yes | 1, 2, or 3 | ≥ 2 copies | NA | Patient is not ventilator dependent* | NA | Neurologist with expertise in SMA |
NA = Payer did not address criterion in their coverage policy; *Permanent ventilation (defined as tracheostomy or ventilatory support for at least 16 h per day for more than 21 continuous days in the absence of an acute reversible event); †Meaningful motor function typically defined as the ability to manipulate objects using upper extremities, walk, etc.
NA not available, SMA spinal muscular atrophy, SMN survival motor neuron