Nusinersen

This policy covers nusinersen (Spinraza) for treatment of spinal muscular atrophy (SMA) — including SMA Types I, II, and III and children clinically or genetically diagnosed with low‑tone neuromuscular/neurological impairment — when a documented 5q SMA genetic abnormality is present and the patient is not ventilator‑dependent (except for noninvasive support limited to naps/night). Initial approval is limited to 6 months, with continuation every 4 months only if a pretreatment baseline motor exam is submitted and there is documented positive clinical response versus baseline on accepted motor scales (HINE‑2, HFMSE, CHOP INTEND, RULM, or 6MWT); concurrent or prior use with onasemnogene abeparvovec (Zolgensma) or risdiplam (Evrysdi) is considered experimental/not covered and coverage is subject to member benefit plan limits and applicable state laws.

"Illinois (per Public Act 103-0458 / 215 ILCS 5/356z."