Louisiana Medicaid Point-of-Sale (POS) Requirements for Selected Enzyme Replacement Therapy Agents
Diagnosis Code Requirement
Diagnosis Code Requirements for Selected ERT Agents Medication Diagnosis Code Brineura™ (cerliponase alfa) E75.4 Neuronal ceroid lipofuscinosis Cerdelga® (eliglustat tartrate) E75.22 Gaucher disease Cerezyme® (imiglucerase) E75.22 Gaucher disease Elelyso® (taliglucerase alfa) E75.22 Gaucher disease Galafold™ (migalastat HCL) E75.21 Fabry (-Anderson) disease E83.39 Other disorders of phosphorus metabolism Strensiq® (asfotase alfa) [perinatal/infantile- and juvenile-onset hypophosphatasia] Vpriv® (velaglucerase alfa) E75.22 Gaucher disease Zavesca® (miglustat) E75.22 Gaucher disease
Fabrazyme® and Galafold™ Therapeutic Duplication POS Edit
These agents are monitored at the pharmacy POS for duplication of therapy with each other.
References
Brineura (cerliponase alfa) [package insert]. Novato, CA: BioMarin Pharmaceutical Inc; March 2020. https://www.brineura.com/wp-content/themes/jupiter-child/assets/pdfs/resources/Brineura- Prescribing-Information.pdf
Cerdelga (eliglustat) [package insert]. Waterford, Ireland: Genzyme Corporation; August 2018. http://products.sanofi.us/Cerdelga/Cerdelga.pdf
Cerezyme (imiglucerase) [package insert]. Cambridge, MA: Genzyme Corporation; April 2018. http://products.sanofi.us/Cerezyme/cerezyme.pdf
Elelyso (taliglucerase alfa) [package insert]. New York, NY: Pfizer Labs; October 2019. http://labeling.pfizer.com/ShowLabeling.aspx?id=798
Galafold (migalastat) [package insert]. Cranbury, NJ: Amicus Therapeutics U.S., Inc; March 2020. https://www.amicusrx.com/pi/galafold.pdf
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Strensiq (asfotase alfa) [package insert]. Boston, MA: Alexion Pharmaceuticals Inc; June 2020. https://alexion.com/documents/strensiq_uspi
Vpriv (velaglucerase alfa) [package insert]. Lexington, MA: Shire Human Genetic Therapies Inc; November 2019. http://pi.shirecontent.com/PI/PDFs/Vpriv_USA_ENG.pdf
Zavesca (miglustat) [package insert]. San Francisco, CA: Actelion Pharmaceuticals Inc; November 2017. https://www.janssenlabels.com/package-insert/product-monograph/prescribing- information/ZAVESCA-pi.pdf
Revision Date Policy created October 2020
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