Description: Galsulfase injection
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 1mg/kg IV every 1 week
Calculate drug reimbursement
(ASP: $34,946.64, Margin: $2,096.80)
# Units to bill:80
Prior auth criteria for Naglazyme may include but is not limited to:
1. Patient must have a confirmed diagnosis of Mucopolysaccharidosis VI (MPS VI).
2. Patient must be at least 6 months of age.
3. Patient must have a urine glycosaminoglycan (GAG) level that is greater than or equal to the upper limit of normal.
4. Patient must have evidence of progressive neurologic deterioration as evidenced by at least one of the following:
- Decrease in gross motor function
- Decrease in fine motor function
- Deterioration in speech and/or language
- Deterioration in cognitive function.
5. Patient must have evidence of progressive skeletal deformities.
6. Patient must have evidence of progressive respiratory impairment.
7. Patient must not have evidence of a hypersensitivity or anaphylactic reaction to Naglazyme.
8. Patient must not be pregnant or lactating.
Insurance prior auth guidelines:
Naglazyme (BIOMARIN PHARMACEUTICAL, INC.)