Payer PolicyActive
Alglucosidase Alfa (Lumizyme)
EVICORE-MEDICAL_DRUG-8C7BA44E
EviCore by Evernorth
Effective: January 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Lumizyme (alglucosidase alfa) is covered only for the FDA‑approved indication of Pompe disease; off‑label uses are excluded. Coverage requires confirmed diagnosis by alpha‑glucosidase enzyme assay or genetic testing with documentation, authorization is for up to 12 months, and prescribers must observe safety monitoring for anaphylaxis, immune‑mediated reactions, and fluid/respiratory/cardiac risks (especially in infantile‑onset or compromised patients).
Coverage Criteria Preview
Key requirements from the full policy
"Lumizyme (alglucosidase alfa) is indicated for the treatment of individuals with Pompe disease."
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