Zolgensma

Zolgensma is a gene therapy approved by the FDA in 2019 to treat spinal muscular atrophy (SMA) in children under two years old. Insurers such as Aetna, UnitedHealthcare, and Blue Cross Blue Shield cover Zolgensma for patients with genetically confirmed SMA type 1 and symptoms before age two.

The average list price of Zolgensma is $2.1 million per single-dose infusion, making it one of the most expensive drugs globally. Prior authorization requirements from insurers often include genetic testing results and clinical documentation of disease severity.

Medicaid programs in states like California, Texas, and New York have published criteria outlining eligibility for Zolgensma coverage, as observed by Your Insurance Info. Out-of-pocket costs vary but can exceed $10,000 if insurance denies or partially covers the treatment.

Appeals processes exist within major insurers for denied claims related to Zolgensma coverage decisions. Patient assistance programs from Novartis provide financial support options for families facing high copays or lack of insurance approval.