Medicare AdvantagePrior AuthMedium impact
Amondys 45 (casimersen) (Revised)
Humana·KY, SC · Neurology, Pediatrics·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Amondys 45 (casimersen) prior authorization policy effective December 17, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy establishes prior authorization requirements for this intravenous exon-skipping therapy in DMD patients, with specific clinical criteria for initial approval and renewal based on functional improvement or maintenance.
Action Required
By December 17, 2025: Billing and prior authorization teams must implement this policy for Amondys 45 (casimersen) claims. (1) Update billing system to require prior authorization for all Amondys 45 intravenous infusions. (2) Configure system to validate all six initial approval criteria before claim submission: DMD diagnosis, confirmed exon 45-amenable mutation, specialist prescriber involvement, corticosteroid status, ambulatory status at initiation, and baseline ambulatory function test documentation (6MWT, 10MWT, or NSAA). (3) For renewal requests, implement system logic to verify member has experienced improvement or maintenance of improvement from predicted disease progression. (4) Update provider portal and billing software to collect required documentation: baseline functional assessments, specialist credentials, and corticosteroid tolerance/contraindication information. (5) Train prior authorization staff on DMD clinical criteria and exon 45 skipping mutation requirements. (6) Ensure claims are rejected and returned to provider if any required criterion is missing. This applies to Medicare and Medicaid members in Kentucky and South Carolina only.