Nova Scotia provides coverage for SMA treatments through Exception Status. Please see below for coverage details of each of the available SMA treatments. Please discuss your eligibility with your health-care provider.

 

SMA Treatments:

Evrysdi (generic name: risdiplam)

• Coverage criteria can be found here by downloading the PDF and searching for ‘Risdiplam’ in the document. For convenience, full coverage criteria is posted below.

 

Full coverage criteria

SPINAL MUSCULAR ATROPHY

For patients diagnosed with 5q Spinal Muscular Atrophy (SMA) under the care of a specialist with experience in the

diagnosis and management of SMA, if the following clinical criteria are met:

• Genetic documentation of 5q SMA homozygous gene deletion or compound heterozygote, AND
• Patients who:

o are symptomatic and have genetic documentation of two or three copies of the SMN2 gene, AND

o aged between 2 months and 7 months (inclusive), OR

o aged 8 months up to 25 years and are non-ambulatory

• Patient is not currently requiring permanent invasive ventilation*, AND
• A baseline assessment using an age-appropriate scale (the Hammersmith Infant Neurological Examination [HINE] Section 2, Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders [CHOP INTEND], or Hammersmith Functional Motor Scale-Expanded [HFMSE]) must be completed prior to initiation of risdiplam treatment.

 

• For continued coverage, the patient must meet the following criteria:

o There is demonstrated achievement or maintenance of motor milestone function (as assessed using ageappropriate scales: the [HINE] Section 2, CHOP INTEND, or HFMSE) after treatment initiation in patients

aged between 2 months and 2 years at the time of treatment initiation; OR

o There is demonstrated maintenance of motor milestone function (as assessed using age-appropriate

scales: the HINE Section 2, CHOP INTEND, or HFMSE) after treatment initiation in patients aged between 2 years and 25 years at the time of treatment initiation; AND

o Patient does not require permanent invasive ventilation*.

 

The decision to discontinue reimbursement should be based on 2 assessments separated by no longer than a 12-week interval.

 

Claim Notes:

Coverage for risdiplam will not be provided in combination with other SMA drug therapies or post administration of onasemnogene abeparvovec.

Approval: 12 months

Claims that exceed the maximum claim amount of $9,999.99 must be divided and submitted as separate transactions using the DIN first and then the following PINs:

00904768

00904769

00904770

* Permanent invasive ventilation is defined as the use of tracheostomy and a ventilator due to progression of SMA that is not due to an identifiable and reversible cause.

Spinraza (generic name: nusinersen)

• Coverage criteria can be found here by downloading the PDF and searching for ‘Nusinersen’ in the document. For convenience, full coverage criteria is posted below.

 

Full coverage criteria

 

For patients diagnosed with 5q Spinal Muscular Atrophy (SMA) under the care of a specialist with experience in the diagnosis and management of SMA, if the following clinical criteria are met:

Genetic documentation of 5q SMA homozygous gene deletion, homozygous mutation, or compound

heterozygote, AND

Patients who:

are pre-symptomatic with two or three copies of SMN2, OR

have had disease duration of less than six months, two copies of SMN2, and symptom onset after the first week after birth and on or before seven months of age, OR

are under the age of 18 with symptom onset after six months of age,

AND

•   Patient is not currently requiring permanent invasive ventilation*, AND
•   A baseline assessment using an age-appropriate scale (the Hammersmith Infant Neurological

Examination [HINE] Section 2, Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders [CHOP INTEND], or Hammersmith Functional Motor Scale-Expanded [HFMSE]) must be completed prior to initiation of nusinersen treatment.

• For continued coverage, the patient must meet the following criteria:

o There is demonstrated achievement or maintenance of motor milestone function (as assessed using ageappropriate scales: the [HINE] Section 2), CHOP INTEND, or HFMSE) since treatment initiation in patients who were pre-symptomatic at the time of treatment initiation; OR

o There is demonstrated maintenance of motor milestone function (as assessed using age-appropriate scales: the HINE Section 2, CHOP INTEND, or HFMSE) since treatment initiation in patients who were symptomatic at the time of treatment initiation;

AND

o Patient does not require permanent invasive ventilation*.

• Treatment should be discontinued if, prior to the fifth dose or every subsequent dose of nusinersen, the above renewal criteria are not met.

 

* Permanent invasive ventilation is defined as the use of tracheostomy and a ventilator due to progression of SMA that is not due to an identifiable and reversible cause.

 

Claim Note:

• Coverage for nusinersen will not be provided in combination with other SMA drug therapies or post administration of onasemnogene abeparvovec.
• Claims for Spinraza 12mg/5mg vials that exceed the maximum claim amount of $9,999.99 must be divided and submitted as separate transactions using the DIN first and then the following PINs:

00904366

00904367

00904368

00904369

00904370

00904371

00904372

00904373

00904374

00904375

00904376

00904377

00904474

00904475

00904476

00904478