Description: Inj, taliglucerase alfa 10 u
Unit: 10 units
Pay quarter: Q4 2023
Dosage and Frequency
• 60 units/kg IV every 2 weeks
Calculate drug reimbursement
(ASP: $20,456.60, Margin: $1,227.40)
# Units to bill:480
Prior auth criteria for Elelyso may include but is not limited to:
1. The patient must have a confirmed diagnosis of Pompe disease, as evidenced by a confirmed genotypic or phenotypic test.
2. The patient must be six years of age or older.
3. The patient must have an expected benefit from treatment, as determined by a healthcare provider in consultation with the patient and their family.
4. The patient must be able to adhere to the recommended schedule of Elelyso infusions.
5. The patient must be willing to comply with laboratory tests and other assessments to monitor response to treatment.
6. The patient must have an adequate body weight for the recommended dosage (at least 10 kg).
7. The patient must not have severe liver impairment.
Insurance prior auth guidelines:
Elelyso (PFIZER INC.)