Elaprase (idursulfase)
Billing
Code: J1743
Description: Idursulfase injection
Unit: 1 mg
Payment: $542.918
Pay quarter: Q3 2023
Dosage and Frequency
Hunter syndrome (Mucopolysaccharidosis II, MPS II)
• 0.5mg/kg IV every 1 week
• 0.5mg/kg IV every 1 week
Calculate drug reimbursement
Total Reimbursement:
$23,019.72(ASP: $21,716.72, Margin: $1,303.00)
Code:
J1743# Units to bill:
40Prior Authorization
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:
Billable NDCs
54092-0700-01
ELAPRASE (TAKEDA PHARMACEUTICALS AMERICA, INC.)
6 MG
Resources