CommercialPrior AuthMedium impact
Eteplirsen (Exondys 51™)
BCBS Tennessee·TN · Neurology, Pediatrics, Genetics·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Eteplirsen (Exondys 51) for Duchenne muscular dystrophy treatment, effective 10/31/2026. The policy covers patients ages 7-13 with confirmed exon 51-amenable DMD mutations who meet ambulatory and corticosteroid criteria, with initial authorization for 6 months and continuation for 12 months. This policy does NOT apply to BlueCare plans.
Action Required
Before 10/31/2026: Billing and clinical teams must establish prior authorization workflows for Eteplirsen (J0898) claims. (1) Update billing system to require prior auth submission for all Eteplirsen requests on applicable BlueCross BlueShield of Tennessee commercial plans (excluding BlueCare). (2) Create prior auth checklist requiring: confirmed DMD diagnosis with genetic testing for exon 51-amenable mutations, proof of 6-minute walk test (6MWT) distance 200-300 meters, corticosteroid use/intolerance documentation, and verification of no prior gene replacement therapy OR documented clinical worsening if previously treated. (3) Implement age verification (7-13 years only) in authorization rules. (4) Configure system to grant initial authorization for 6 months and subsequent authorizations for 12 months if member remains ambulatory. (5) Ensure prescriber verification that physician specializes in DMD treatment. (6) Train prior auth staff on dose limit (max 30 mg/kg weekly). (7) Update provider communications to explain new authorization requirement. Claims submitted without completed prior authorization will be denied. This policy becomes enforceable on the effective date; work must begin immediately to meet the 10/31/2026 deadline.