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Anthem Revises Policy for EXONDYS 51, Deemed Medically Necessary for Ambulatory Patients

Progress! Today, Anthem issued a revised policy regarding Sarepta’s EXONDYS 51. In the revision, Anthem declared EXONDYS 51 medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met:

  1. Individual has a confirmed diagnosis of Duchenne muscular dystrophy; and
  2. Individual must be ambulatory (with or without needing an assistive device, such as a cane or walker); and
  3. Individual has a genetic mutation that is amenable to exon 51 skipping.

Continuation of therapy with eteplirsen, for each 12 month period post initiation of therapy, is considered medically necessary for the treatment of Duchenne muscular dystrophy when all of the following criteria are met:

  1. The criteria above for initiation of therapy have been met; and
  2. Individual remains ambulatory (with or without needing an assistive device, such as a cane or walker).

In our discussions with Anthem, PPMD has learned that anyone who has been denied coverage in the past does have a pathway forward for appeal with the company based on today’s new policy determination if you/your child meets the criteria.

 

While this redefined policy comes with some pretty big stipulations still, it is definite progress and we believe a positive sign that payers are evolving when it comes to covering Duchenne.

 

Many families continue to struggle with insurance companies – not only to cover EXONDYS 51, but Emflaza, and a litany of other treatments, supplements, and devices we as a community know to be medically necessary. PPMD is committed to helping families navigate this complex access environment. We believe that approved therapies should be available to those who need them — and we will continue to work until every eligible community member has access.

 

Today is a victory for all of us. While Anthem is only one payer changing their policy for one drug, there is now a precedent that we hope will positively influence other public and private payers as they approach the data available and consider their policy determinations. And this victory is because we engaged with Anthem to work towards access and will continue to work as a community for what we deserve – therapies for all, access for all.

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