Medical Policy

Effective Date:01/01/2015 Title:Cerdelga (Eligustat)
Revision Date: Document:BI468:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cerdelga (eligustat) requires prior authorization.

2)    Cerdelga is used to treat Gaucher’s disease.

3)    Cerdelga is a specialty medication and must be obtained through the contracted specialty pharmacy.

Medical Statement

1)    Cerdelga (eligustat) is considered medically necessary for the long-term treatment of patients with Gaucher’s disease type 1 (GD1) who are cytochrome P450 2D6 (CYP2D6) extensive metabolizers (Ems), intermediate metabolizers (IMs), or poor metabolizers (PMs). 

2)    Cerdelga is not covered for ultra-rapid metabolizers.

Limits

1)    As a specialty drug, Cerdelga is limited to no more than a 30 day supply per fill.

2)    Cerdelga is limited based on the metabolizer status of the patient as follows:

a.    For Ems and IMs, two capsules per day.

b.    For PMs, one capsule per day.

Reference

1)    Cerdelga Product Information.  Genzyme Corporation.  August 2014.

2)    Clinical Pharmacology.  Accessed online November 17, 2014.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.