Payer PolicyActive
Naglazyme® (galsulfase)
EVICORE-MEDICAL_DRUG-E4DDCCB4
EviCore by Evernorth
Effective: June 1, 2024
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Naglazyme is covered only for the FDA‑approved indication of mucopolysaccharidosis type VI (MPS VI) and is excluded for other uses. Approval (12 months) requires confirmed diagnosis by deficient arylsulfatase B enzyme activity or N‑acetylgalactosamine 4‑sulfatase gene mutation, prescription by or consultation with a geneticist/endocrinologist/metabolic/lysosomal-disorder specialist, dosing at 1 mg/kg IV weekly, documentation of tests, patient weight and infusion records, and adherence to applicable safety criteria.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of mucopolysaccharidosis type VI (MPS VI; Maroteaux-Lamy Syndrome)."
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