Aldurazyme® (laronidase)

Authorization forms

Traditional, Optimized, & Medicaid (05/2019)

 

Medicare: No prior authorization required

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J1931

Benefit: Medical

Notes: Treatment of mucopolysaccharideosis I (MPS I)

Criteria for coverage: See PA forms