Kanuma

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

January 2018

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
  • Documentation 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