60923-0363-XX Exondys-51 100 MG/2ML SOLN (SAREPTA THERAPEUTICS)
|60923-0284-XX Exondys-51 500 MG/10ML SOLN (SAREPTA THERAPEUTICS)|
Eteplirsen is an antisense oligonucleotide indicated for the treatment of Duchenne muscular dystrophy. Eteplirsen is designed to bind to exon 51 of dystrophin pre-mRNA, resulting in exclusion of this exon during mRNA processing in individuals with genetic mutations that are amenable to exon 51 skipping. Exon skipping is intended to allow for production of an internally truncated dystrophin protein. Eteplirsen treated individuals were found to produce messenger ribonucleic acid (mRNA) for a truncated dystrophin protein by reverse transcription polymerase chain reaction.
Eteplirsen for the treatment of Duchenne muscular dystrophy is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Eteplirsen for the treatment of other conditions/diseases is considered investigational.
Eteplirsen is considered medically appropriate if ALL of the following criteria are met:
Confirmed mutation of the Duchenne muscular dystrophy (DMD) gene
The individual has been on a stable dose of corticosteroids for at least 6 months
The individual retains meaningful voluntary motor function (e.g., able to speak, manipulate objects using upper extremities, ambulate)
The individual is receiving physical therapy
Eteplirsen is considered medically appropriate for renewal if ALL of the following criteria are met:
Individual continues to meet the initial approval criteria
Individual has received benefit from therapy, which may include an increase in dystrophin, an improvement in 6-minute walk test and/or improvement in quality of life
Absence of unacceptable toxicity from the agent (e.g., balance disorders, vomiting, etc.)
DOSAGE & ADMINISTRATION
Duchenne muscular dystrophy
30 mg / kg administered once weekly as a 35 to 60 minute intravenous infusion
LENGTH OF AUTHORIZATION
Coverage will be provided for 6 months and may be renewed.
Refer to DOSAGE LIMITS below
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
Lexicomp Online. (2019, February). AHFS DI. Eteplirsen. Retrieved June 6, 2019 from Lexicomp Online with AHFS.
MICROMEDEX Healthcare Series. Drugdex Evaluations. (2018, October). Eteplirsen. Retrieved June 6, 2019 from MICROMEDEX Healthcare Series.
U. S. Food and Drug Administration. (2018, October). Center for Drug Evaluation and Research. Exondys 51™ (eteplirsen). Retrieved June 6, 2019 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/206488s009lbl.pdf.
ORIGINAL EFFECTIVE DATE: 11/24/2017
MOST RECENT REVIEW DATE: 7/9/2019
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.
Maximum billable units per dose and over time by indication as a Medical Benefit; 1 billable unit = 10 mg