Brineura® (cerliponase alfa)

Authorization form

Traditional & Optimized (07/2018)

Medicare Part B (05/2018)

 

Not covered for Medicaid

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J0567

Benefit: Medical

Notes: For the treatment of patients with late-infantile neuronal ceroid lipofuscinosis type 2 (CLN2) disease, a form of Batten disease