For our commercial members, Harvard Pilgrim requires prior authorization for the medication Brineura, effective immediately. Brineura was approved by the Food and Drug Administration last year, and is used to slow the loss of ambulation in symptomatic pediatric patients 3 years of age and older with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2).
To receive prior authorization for a commercial member, the following criteria must be met:
- Diagnosis of CLN2 was confirmed by enzyme assay demonstrating a deficiency of tripeptidyl peptidase 1 (TPP1) enzyme activity or by genetic testing.
- Brineura is prescribed to slow the loss of ambulation in symptomatic members.
- Member is 3 years of age or older.
- Brineura will be administered by, or under the direction of, a physician knowledgeable in intraventricular administration.
As a reminder, CVS Health–NovoLogix oversees our prior authorization program for medical drugs to optimize treatment outcomes and promote the safe and cost-effective use of these medications. To request authorization for Brineura, please contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882). For complete information, please refer to our new Brineura Medical Review Criteria and the associated prior authorization request form.