Exondys 51® (Eteplirsen) – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers Exondys 51 only for Duchenne muscular dystrophy patients with a confirmed DMD mutation amenable to exon 51 skipping and excludes use for non‑exon‑51‑amenable DMD, other muscular dystrophies (e.g., Becker), or concomitant exon‑skipping therapies. Coverage requires mutation confirmation and clinical documentation of ambulatory status (6MWT ≥300 m walking independently OR ambulatory without assistive device plus NSAA >17 or TTR <7 s), prescription by or in consultation with a DMD‑expert neurologist, FDA‑label dosing, documentation regarding prior gene therapy (with demonstrated post‑therapy functional decline if applicable), and authorization is limited to 12‑month intervals.

"Treatment of Duchenne muscular dystrophy (DMD) in patients who have a confirmed mutation of the DMD gene that is amenable to exon 51 skipping."

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