Table 3 Payer coverage criteria for nusinersen for spinal muscular atrophy
From: Patients’ access to rare neuromuscular disease therapies varies across US private insurers
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 |