Description: Idursulfase injection
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 0.5mg/kg IV every 1 week
Calculate drug reimbursement
(ASP: $20,487.43, Margin: $1,229.25)
# Units to bill:40
Prior auth criteria for Elaprase may include but is not limited to:
1. The patient must be 6 years of age or older.
2. The patient must have been diagnosed with Hunter syndrome (mucopolysaccharidosis II).
3. The patient must have experienced a decline in physical, cognitive, or behavioral function as measured by at least one of the following assessments: Bayley Scales of Infant Development-III (BSID-III), Vineland Adaptive Behavior Scales (VABS), or Psychoeducational Profile-Revised (PEP-R).
4. The patient must have had a total lysosomal enzyme activity level test and the results must have revealed an activity level of ?2% of normal.
5. The patient must not have received Elaprase in the past.
6. The patient must not have any known hypersensitivity to the active ingredient, iduronate-2-sulfatase.
7. The patient must not be pregnant or breastfeeding.
8. The patient must not have any other medical condition that may increase the risk of adverse reactions from Elaprase.
Insurance prior auth guidelines:
ELAPRASE (TAKEDA PHARMACEUTICALS AMERICA, INC.)