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SPINRAZA nusinersen PRIOR AUTHORIZATION Physician Fax Form Clear Data BCBS Kansas REQUIRES that this form be completed by the prescriber. Yes Homozygous deletion of SMN1 gene Homozygous absence of SMN1 gene due to gene conversion i.e. SMN1 gene conversion to SMN2 gene Compound heterozygous mutation of SMN1 gene If yes please provide supporting documentation Continued on the next page. Covermymeds. com For formulary information please visit the Blue Cross and Blue Shield of Kansas website...

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