Amondys 45 Becomes a Benefit for Texas Medicaid and CHIP

Call to Action
The Texas Health and Human Services Commission (HHSC) will cover Amondys 45, billed under the Healthcare Common Procedure Code (HCPCS) J3490 from June 1 until June 30, 2021. Beginning July 1, 2021, HHSC will cover Amondys 45 under CMS-issued code C9075. Amondys 45 is indicated to treat Duchenne muscular dystrophy (DMD).

Billing Requirements
From June 1 until June 30, 2021 use code J3490 with description Amondys 45 on the claim.
As of July 1, 2021, submit claims with code C9075 for reimbursement.

Prior authorization guidance for Amondys 45
An initial request for Amondys 45 (Casimersen) must include the following documentation to support medical necessity:

• Genetic testing must confirm that the client’s DMD gene is amenable to exon 45
• Serum cystatin C, urine dipstick and urine protein-to-creatinine ratio should be measured prior to initiating therapy.
• Baseline renal function test (i.e., Glomerulus Filtration Rate) and urine protein-to-creatinine ratio should be measured before starting treatment.
• Current client weight, including the date the weight was obtained. The weight must be dated no more than 30 days before the request date.
• Available testing tools to demonstrate physical function include, but are not limited to:
  • Brooke Upper Extremity Scale.
  • Baseline 6MWT (6-minute walk test).
  • North Star Ambulatory Assessment.
• Amondys 45 should not be used concomitantly with other exon-skipping therapies for DMD.

A recertification/extension request for Amondys 45 must include documentation of the following:

• Continual renal function monitoring while on Amondys 45 therapy.
  • The client’s current weight and the date on which the weight was obtained. The weight must be dated no more than 30 days before the request date.

Amondys 45 should not be continued as a treatment for clients who experience decreasing physical function while on the medication.

Questions
Contact our BCBSTX Medicaid Provider Service Center at 1-877-560-8055 or contact your BCBSTX Medicaid Provider Network Representative at 1-855-212-1615.

Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.