Idursulfase (Elaprase®)
Defines prior authorization, documentation, initial and continuation coverage criteria, and prescriber requirements for idursulfase (Elaprase) for treatment of MPS II (Hunter syndrome) under BlueCross BlueShield of Tennessee.
Document indicates proposed additions and deletions (red text and strikethrough) but is labeled 'Medical Policy Manual Draft Revision Policy: Do Not Implement'.
Coverage Summary & Indications
Coverage stance: Covered with criteria for treatment of MPS II (Hunter syndrome). Scope: defines prior authorization, documentation requirements, initial and continuation coverage criteria, and prescriber requirements for idursulfase (Elaprase) under the plan. Covered indication: Elaprase (idursulfase) for Mucopolysaccharidosis II (Hunter syndrome) when the specified clinical and diagnostic criteria are met. Authorization may be granted for 12 months.