Table 5 Payer coverage criteria for eteplirsen for Duchenne muscular dystrophy
From: Patients’ access to rare neuromuscular disease therapies varies across US private insurers
Plan covers therapy? | Plan imposes additional coverage criteria | 6-min walk test (meters) | Ambulation/motor function | Age requirement | Prior therapy with glucocorticoids | Prescriber requirement | |
|---|---|---|---|---|---|---|---|
Plan 1 | Yes | Yes | ≥ 180 m | NA | Therapy initiated < 14 years of age | NA | Neurologist with expertise in DMD |
Plan 2 | Yes | Yes | NA | Ambulation with or without assistance | NA | NA | NA |
Plan 3 | Yes | Yes | ≥ 300 m | Ambulation with or without assistance | NA | NA | Neurologist |
Plan 4 | Yes | Yes | NA | Ambulation without assistance | NA | NA | Neurologist |
Plan 5 | No | NC | NC | NC | NC | NC | NC |
Plan 6 | No | NC | NC | NC | NC | NC | NC |
Plan 7 | No | NC | NC | NC | NC | NC | NC |
Plan 8 | Yes | Yes | NA | Voluntary motor function (e.g. ambulate, able to speak, manipulate objects) | NA | Yes | NA |
Plan 9 | Yes | Yes | ≥ 180 m | NA | Therapy initiated < 14 years of age | NA | NA |
Plan 10 | Yes | Yes | ≥ 200 m | Ambulation with or without assistance | Therapy initiated < 13 years of age | Yes | Neurologist |
Plan 11 | Yes | Yes | NA | Ambulation with or without assistance | NA | NA | NA |
Plan 12 | Yes | Yes | ≥ 300 m | Ambulation without assistance | Patient is ≥ 7 years | Yes | Neurologist with expertise in DMD |
Plan 13 | No | NC | NC | NC | NC | NC | NC |
Plan 14 | No | NC | NC | NC | NC | NC | NC |
Plan 15 | Yes | Yes | NA | Ambulation with or without assistance | NA | NA | NA |
Plan 16 | No policy | No policy | No policy | No policy | No policy | No policy | No policy |
Plan 17 | Yes | Yes | ≥ 300 m | Ambulation without assistance | NA | NA | Neurologist with expertise in DMD |