MedicaidPrior AuthMedium impact
BT202157: IHCP aligns PA criteria for nusinersen (Spinraza)
Indiana Medicaid (IHCP)·IN · Neurology, Pediatrics·Provider Bulletin
Effective date
Jul 1, 2021
We identified it
Jun 19, 2026
Summary
Indiana Health Coverage Programs (IHCP) has aligned prior authorization criteria for nusinersen (Spinraza) between pharmacy and medical benefits, requiring specific genetic testing documentation and SMA diagnosis confirmation. The policy also establishes continuation criteria and identifies when the drug is not considered medically necessary.
Action Required
Billing team must ensure prior authorization is obtained for HCPCS code J2326 (nusinersen injection) with documentation of SMA diagnosis via genetic testing (zero copies SMN1 gene or molecular genetic testing) and either genetic testing showing no more than three copies of SMN2 gene or SMA symptoms before 6 months of age. For continuation beyond six months, document clinically significant improvement in motor function. Do not bill if patient has received Onasemnogene Abeparvovec-xioi or is using concurrent risdiplam.