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Kanuma

Drug - Kanuma™ (sebelipase alfa) [Alexion Pharmaceuticals, Inc.]

September 2016

Therapeutic area - Enzyme replacement therapy

Approval criteria

  • Have a diagnosis of one of the following forms of Lysosomal Acid Lipase (LAL) deficiency:
    • Wolman disease
    • Cholesteryl ester storage disease (CESD) AND
  • Must be prescribed by a provider specializing in genetics and metabolism AND
  • Provider’s specialty must be provided at time of request
  • Documentation of diagnosis from patient’s medical records must be provided at time of request

Quantity limits

  • Infants 0-6 months of age: 3mg/kg weekly
  • Patients 4 years of age and older: 1mg/kg every other week
  • Patient’s most current weight (rounded to the nearest kg) must be provided at time of request

Approvals

  • Initial approval will be limited to 6 months in duration
  • Renewal approval will be limited to 6 months in duration 
    • Renewals must be prescribed by a provider specializing in genetics and metabolism AND
    • Provider’s specialty must be provided at time of request AND
    • Chart notes must be supplied at time of request showing patient is responsive to treatment

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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