Payer PolicyActive
Alglucosidase Alfa (Lumizyme)
EVICORE-MEDICAL_DRUG-6AC6C4C1
EviCore by Evernorth
Effective: October 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Lumizyme (alglucosidase alfa) is covered only for Pompe disease (acid α‑glucosidase deficiency) and is not covered for non‑FDA indications. Approval (up to 12 months) requires confirmed diagnosis by deficient enzyme activity in blood/fibroblasts/muscle or by molecular genetic testing, prescription by or consultation with a geneticist/neurologist/metabolic or lysosomal storage disorders specialist, and dosing limited to 20 mg/kg IV no more frequently than every 2 weeks.
Coverage Criteria Preview
Key requirements from the full policy
"Lumizyme (alglucosidase alfa) is indicated for the treatment of individuals with Pompe disease (acid α-glucosidase deficiency)."
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