CommercialCoverageMedium impact
08.00.72l, Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme® ), Cipaglucosidase alfa-atga (Pombiliti™ )
Independence Blue Cross·Hematology, Neurology, Pediatrics +1 more·Pharmacy
Effective date
Nov 26, 2025
We identified it
Jun 19, 2026
Summary
This policy reissue (effective 11/26/2025) addresses coverage and billing requirements for three enzyme replacement therapies: Alglucosidase alfa (Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), and Cipaglucosidase alfa-atga (Pombiliti™). The billing team must review the full policy text to identify specific coverage criteria, prior authorization requirements, and billing code changes that may impact claims processing for these specialty pharmaceutical products.
Action Required
By 11/26/2025: Billing team must access the full policy text at https://medpolicy.ibx.com/ibc/Commercial/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=11&FilterField2=MPSiteActivityLogYear&FilterValue2=2025#commercial-08-00-72l to extract specific HCPCS codes (J-codes), prior authorization requirements, and coverage limitations for these three enzyme replacement therapies. Update billing system, prior authorization workflows, and claim submission procedures accordingly. Notify providers prescribing these medications of any new documentation or authorization requirements. Failure to implement changes may result in claim denials or payment delays for affected patients.