Payer PolicyActive
Galsulfase (Naglazyme)
EVICORE-MEDICAL_DRUG-962151B5
EviCore by Evernorth
Effective: September 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Naglazyme (galsulfase) is covered only for the FDA‑approved indication mucopolysaccharidosis type VI (MPS VI/Maroteaux‑Lamy Syndrome); other indications are not covered. Approval requires enzyme assay showing deficient N‑acetylgalactosamine 4‑sulfatase (arylsulfatase B) activity or molecular genetic confirmation, prescription or consultation with a geneticist/endocrinologist/metabolic or lysosomal storage disorder specialist, is authorized for 12 months, and dosing is limited to 1 mg/kg IV no more frequently than once weekly.
Coverage Criteria Preview
Key requirements from the full policy
"Naglazyme (galsulfase) is indicated for the treatment of mucopolysaccharidosis type VI (MPS VI; Maroteaux-Lamy Syndrome)."
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