BlueCross BlueShield of Tennessee Medical Policy Manual

Casimersen (Amondys 45™)

MPORTANT REMINDER

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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

POLICY

1. INDICATIONS

The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

FDA-Approved Indication

Amondys 45 is indicated for the treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 45 skipping.

This indication is approved under accelerated approval based on an increase in dystrophin production in skeletal muscle observed in patients treated with Amondys 45. Continued approval for this indication may be contingent upon verification of a clinical benefit in confirmatory trials.

All other indications are considered experimental/investigational and not medically necessary.

2. DOCUMENTATION

Submission of the following information is necessary to initiate the prior authorization review:

1. Initial requests:

1. Laboratory confirmation of Duchenne muscular dystrophy (DMD) diagnosis with a DMD gene mutation that is amenable to exon 45 skipping (refer to examples in Appendix).
2. If applicable, medical records confirming a worsening in clinical status since receiving gene replacement therapy.

2. Continuation of therapy requests: documentation (e.g., chart notes) of response to therapy.

3. PRESCRIBER SPECIALTIES

This medication must be prescribed by or in consultation with a physician who specializes in the treatment of Duchenne muscular dystrophy (DMD).

4. CRITERIA FOR INITIAL APPROVAL

Duchenne Muscular Dystrophy

Authorization of 6 months may be granted for treatment of DMD when all of the following criteria are met:

1. Genetic testing was conducted to confirm the diagnosis of DMD and to identify the specific type of DMD gene mutation.
2. The DMD gene mutation is amenable to exon 45 skipping (refer to examples in Appendix).
3. Treatment with Amondys 45 is initiated before the age of 14.
4. Member is able to achieve an average distance of at least 300 meters while walking independently over 6 minutes.
5. Member meets one of the following criteria:

1. Member has not previously received gene replacement therapy for DMD (e.g., Elevidys).
2. Member has previously received gene replacement therapy for DMD (e.g., Elevidys) and has experienced a worsening in clinical status since receiving gene replacement therapy (e.g., decline in ambulatory function).

6. Member will not exceed a dose of 30 mg/kg once weekly.

5. CONTINUATION OF THERAPY  

Note: Members who were previously established on Amondys 45 and subsequently administered gene replacement therapy (e.g., Elevidys) must meet all initial criteria prior to re-starting Amondys 45.

Authorization of 12 months may be granted for members requesting continuation of therapy when all of the following criteria are met:

1. The member has demonstrated a response to therapy as evidenced by remaining ambulatory (e.g., able to walk with or without assistance, not wheelchair dependent).
2. The member will not exceed a dose of 30 mg/kg once weekly.

6. APPENDIX     

Examples of DMD gene mutations (exon deletions) amenable to exon 45 skipping (not an all-inclusive list):

1. Deletion of exon 44
2. Deletion of exon 46-47
3. Deletion of exon 46-48
4. Deletion of exon 46-49
5. Deletion of exon 46-51
6. Deletion of exon 46-53
7. Deletion of exon 46-55

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTSS

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.

ADDITIONAL INFORMATION  

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).

REFERENCES

1. Amondys 45 [package insert]. Cambridge, MA: Sarepta Therapeutics; March 2023.
2. ClinicalTrials.gov. Study of SRP-4045 and SRP-4053 in DMD patients (ESSENCE). Available at:  https://clinicaltrials.gov/ct2/show/NCT02500381. Accessed March 1, 2021.
3. Fletcher, S., et. al. Dystrophin Isoform Induction In Vivo by Antisense-mediated Alternative Splicing. The American Society of Gene & Cell Therapy. 2010;18(6):1218-1223.
4. Polavarapu K, Preethish-Kumar V, Sekar D, et al. Mutation pattern in 606 Duchenne muscular dystrophy children with a comparison between familial and non-familial forms: a study in an Indian large single-center cohort. J Neurol. 2019;266(9):2177-2185.

ORIGINAL EFFECTIVE DATE: 6/2/2021

MOST RECENT REVIEW DATE: 12/10/2024

ID_CHS

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.