Medicare AdvantagePrior AuthMedium impact
Vimizim® (elosulfase alfa) (Revised)
Humana·SC, VA · Pediatrics, Genetics, Internal Medicine·Medicaid
Effective date
Mar 6, 2014
We identified it
Jun 25, 2026
Summary
This is a revised Humana prior authorization policy for Vimizim (elosulfase alfa) for treatment of Mucopolysaccharidosis IVA (MPS IVA; Morquio A Syndrome), updated January 28, 2026. The policy requires prior authorization and applies to Medicare, Medicaid in South Carolina, and Medicaid in Virginia. The single approval criterion is confirmed diagnosis of MPS IVA, with approvals granted for plan year durations for both initial and renewal requests.
Action Required
By February 28, 2026: Billing team must update prior authorization workflows to reflect the revised Vimizim (elosulfase alfa) policy. Verify that all Vimizim claims submitted for Medicare, Medicaid-South Carolina, and Medicaid-Virginia members include documented diagnosis of Mucopolysaccharidosis IVA (MPS IVA; Morquio A Syndrome). Prior authorization requests must be submitted before treatment initiation. Alert clinical staff to the updated Black Box Warning regarding anaphylaxis risk and ensure infusion centers are prepared to manage acute hypersensitivity reactions. Note that approval duration is plan year-based for both initial and renewal requests. Refer to www.humana.com/PAL for applicable procedure coding. Failure to obtain prior authorization will result in claim denials.