Payer PolicyActive
Olipudase Alfa-rpcp (Xenpozyme™)
EVICORE-MEDICAL_DRUG-72E3B237
EviCore by Evernorth
Effective: January 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Covered: Olipudase alfa (Xenpozyme) is authorized for non‑CNS manifestations of ASMD in adults and pediatrics with ASMD type B or A/B (ASMD type A alone and CNS manifestations are excluded). Key requirements: documented enzymatic assay and clinical signs of ASMD, prescription by or consultation with a geneticist/endocrinologist/metabolic/lysosomal disorders specialist, weight‑based IV dosing every 2 weeks with specified escalation to 3 mg/kg (use adjusted body weight if BMI>30), and approval limited to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Xenpozyme is indicated for the treatment of non-central nervous system (CNS) manifestations of acid sphingomyelinase deficiency (ASMD) in adult and pediatric patients"
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