Vimizim® (elosulfase alfa)

Authorization forms

Traditional & Optimized (05/2019)

Medicare Part B (05/2018)


This is a carve-out for Medicaid. Contact fee-for-service Medicaid for coverage.

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): J1439

Benefit: Medical

Notes: Enzyme replacement for Morquio A Syndrome

Criteria for coverage:

  • See PA form for criteria for Commercial

  • Not Covered for Medicaid