Payer PolicyActive
Idursulfase (Elaprase)
EVICORE-MEDICAL_DRUG-112A86E8
EviCore by Evernorth
Effective: September 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Idursulfase (Elaprase) is covered only for the FDA‑approved indication of mucopolysaccharidosis type II (Hunter syndrome); uses for other indications are not supported. Coverage requires confirmation by deficient iduronate‑2‑sulfatase activity (leukocytes, fibroblasts, serum/plasma) or molecular genetic testing, prescription by or consultation with a geneticist/endocrinologist/metabolic disorder or lysosomal storage disorder specialist, dosing ≤0.5 mg/kg IV no more than once weekly, and authorization is limited to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of individuals with mucopolysaccharidosis type II (MPS II; Hunter syndrome) — FDA-approved indication."
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