Lumizyme (alglucosidase alfa)
Billing
Code: J0221
Description: Lumizyme injection
Unit: 10 mg
Payment: $194.915
Pay quarter: Q3 2023
Dosage and Frequency
Pompe disease
• 20mg/kg IV every 2 weeks
• 20mg/kg IV every 2 weeks
Calculate drug reimbursement
Total Reimbursement:
$33,057.58(ASP: $31,186.40, Margin: $1,871.18)
Code:
J0221# Units to bill:
160Prior Authorization
Prior auth criteria for Lumizyme may include but is not limited to:
1. Patient must be diagnosed with Pompe Disease (GAA deficiency).
2. Patient must be at least 2 years of age.
3. Patient must have an appropriate baseline body weight and body mass index (BMI) for their age.
4. Patient must have an appropriate baseline level of respiratory function as determined by spirometry or other appropriate pulmonary function test.
5. Patient must have been treated with enzyme replacement therapy for at least 6 months prior to initiation of Lumizyme treatment.
6. Patient must have stable overall clinical status and not require urgent intervention.
7. Patient must not have any contraindications to Lumizyme treatment, such as hypersensitivity or anaphylaxis.
8. Patient must not be pregnant or breastfeeding.
9. Patient must not have a history of significant adverse reactions to Lumizyme or any of its components.
10. Patient must have received appropriate counseling regarding the risks and benefits associated with Lumizyme treatment.
Insurance prior auth guidelines:
Billable NDCs
58468-0160-01
Lumizyme (GENZYME CORPORATION)
50 MG
58468-0160-02
Lumizyme (GENZYME CORPORATION)
500 MG
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