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Prior Authorization Criteria Added for Casimersen (Amondys 45) Effective September 1, 2021

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after September 1, 2021, prior authorization will be required for antisense oligonucleotide casimersen (Amondys 45) procedure code C9075 for Texas Medicaid.

Initial Requests

An initial request for casimersen (Amondys 45) must include the following documentation to support medical necessity:

  • Genetic testing must confirm that the client’s Duchenne muscular dystrophy (DMD) gene is amenable to exon 45 skipping.
  • Serum cystatin C, urine dipstick, and urine protein-to-creatinine ratio should be measured prior to initiating casimersen (Amondys 45).
  • Monitor baseline renal function (i.e., Glomerulus Filtration Rate, GFR) with therapy initiation and continuation.
  • Current client weight, including the date the weight was obtained; the weight must be dated no more than 30 days before the request date.

Testing tools that can be used to demonstrate physical function include, but are not limited to:

  • Baseline 6MWT (6-minute walk test)
  • Brooke Upper Extremity Scale
  • North Star Ambulatory Assessment

Casimersen (Amondys 45) should not be used concomitantly with other exon skipping therapies for DMD.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.7.1.1 “Initial Requests (for all Antisense Oligonucleotides),” for additional documentation requirements that apply to all antisense oligonucleotides.

Recertification/Extension Request

A recertification/extension request for casimersen (Amondys 45) must include the following documentation:

  • Continual renal function test while on casimersen (Amondys 45) therapy.
  • The client’s current weight, including the date the weight was obtained. The weight must be dated no more than 30 days before the request date.

Casimersen (Amondys 45) should not be continued on clients who experience decreasing physical function while on the medication.

Casimersen (Amondys 45) should not be used concomitantly, or with other exon shipping therapies for DMD.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.7.1.2 “Recertification/Extension Requests (for all Antisense Oligonucleotides),” for the additional documentation requirements that apply to all antisense oligonucleotides.

For more information, call the TMHP Contact Center at 800-925-9126.