Nulibry® (fosdenopterin)

Nulibry (fosdenopterin) is covered only for the FDA‑approved indication of reducing mortality in molybdenum cofactor deficiency (MoCD) Type A and is not covered for other MoCD types or non‑FDA uses. Coverage (initial and renewal, up to 12 months) requires documented MOCS1 mutation, clinical documentation that the disease is not too advanced and the patient is expected to benefit, prescription by or in consultation with a pediatrician/geneticist/MoCD specialist, IV age‑ and weight‑based dosing per the labeled neonatal titration or mg/kg regimen for ≥1 year, and supporting records (genetic test report, clinical notes, prescriber/consultation documentation, age/weight, and infusion orders/administration).

""Patient has genetic testing confirmation of a mutation in the MOCS1 gene."

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