Agalsidase beta (Fabrazyme®) - Minnesota Health Care Programs
These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Agalsidase beta (Fabrazyme) requires prior authorization from HealthPartners Pharmacy Administration.
Fabrazyme is generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
Fabrazyme is generally covered when:
- Prescribed by a specialist; and,
- Prescribed for treatment of Fabry disease using the FDA-approved regimen and,
- The patient and/or guardian has attested that they will adhere to the treatment plan
Initial approvals will be for twelve months.
Annual reauthorizations will require medical chart documentation that the patient has been seen within the past 12 months and that markers of disease are improved by therapy. These include but may not be limited to routine hematology and chemistry profiles to assess renal function and a statement of progress against therapy goals.
Fabrazyme is indicated for use in patients with Fabry disease. Fabrazyme reduces globotriaosylceramide (GL-3) deposition in capillary endothelium of the kidney and certain other cell types.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Injection, agalsidase beta, 1mg
Fabrazyme 35 MG SOLR
Fabrazyme 5 MG SOLR
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- Fabrazyme Prescribing Information. Cambridge, MA. Genzyme Corporation, July 2010.