CommercialPrior AuthMedium impact
Imiglucerase (Cerezyme®)
BCBS Tennessee·TN · Genetics, Pediatrics, Internal Medicine·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
BlueCross BlueShield of Tennessee is implementing a new medical policy for Imiglucerase (Cerezyme®) effective October 31, 2026, establishing coverage criteria for Gaucher disease types 1, 2, and 3. The policy requires prior authorization with specific diagnostic documentation (enzyme assay or genetic testing) and evidence of clinical disease manifestations at baseline. Authorization is granted for 12-month periods with continuation requiring documented therapeutic benefit.
Action Required
By October 31, 2026: Billing and prior authorization teams must implement this new policy for BlueCross BlueShield of Tennessee members. (1) Update prior authorization system to require initial requests include beta-glucocerebrosidase enzyme assay or genetic testing results plus chart documentation of baseline clinical signs (bone disease, splenomegaly, hepatomegaly, cytopenia). (2) Configure continuation authorization requests to require documentation of therapeutic benefit (improved liver/spleen volume, hemoglobin, platelet counts). (3) Set medication quantity limit to maximum dosing of 60 Units/kg intravenously every 2 weeks for all Gaucher disease diagnoses. (4) Verify treating physician specialty—Imiglucerase must be prescribed by or in consultation with physicians knowledgeable in Gaucher disease management; flag non-compliant orders. (5) Train billing and auth staff that only Gaucher disease types 1, 2, and 3 are covered; all other indications are experimental/investigational and not medically necessary. (6) Do not process claims or issue authorizations before 10/31/26 as policy states 'Do Not Implement until 10/31/26.' Failure to implement prior authorization requirements will result in claim denials.