Payer PolicyActive
Agalsidase Beta (Fabrazyme®)
EVICORE-MEDICAL_DRUG-1B075437
EviCore by Evernorth
Effective: July 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered only for the FDA‑approved indication of Fabry disease, with dosing limited to 1 mg/kg IV no more frequently than every 2 weeks and approvals issued for up to 12 months; use for non‑FDA indications is not supported. Approval requires documented diagnostic confirmation (deficient α‑galactosidase A activity in leukocytes or fibroblasts or a pathogenic GLA mutation) and prescription by or consultation with a geneticist, endocrinologist, metabolic disorder specialist, or other physician specializing in lysosomal storage disorders.
Coverage Criteria Preview
Key requirements from the full policy
"Fabrazyme (agalsidase beta) is indicated for the treatment of individuals with Fabry disease."
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