Payer PolicyActive
Elosulfase Alfa (Vimizim)
EVICORE-MEDICAL_DRUG-1317760E
EviCore by Evernorth
Effective: January 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Vimizim (elosulfase alfa) is covered only for the FDA‑approved treatment of Mucopolysaccharidosis type IVA (Morquio A) and off‑label uses are excluded. Coverage requires patients be ≥5 years with diagnosis confirmed by galactose‑6‑sulfatase enzyme assay or genetic testing, is authorized for up to 12 months (reauthorization needed), and administration precautions include premedication for hypersensitivity and delaying infusion for acute febrile/respiratory illness because of anaphylaxis risk.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of individuals with Mucopolysaccharidosis type IVA (MPS IVA; Morquio A syndrome) (FDA-approved indication)."
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