CurrentViva HealthPolicy IC-0615
Nexviazyme (avalglucosidase alfa-ngpt) (Intravenous)
Defines prior authorization, coverage criteria, dosing, renewal rules, billing codes, and limits for Nexviazyme (avalglucosidase alfa-ngpt) for treatment of late-onset Pompe disease for Viva Health members.
Policy Summary
PayerViva Health
PolicyNexviazyme (avalglucosidase alfa-ngpt) (Intravenous)
Policy CodePolicy IC-0615
Change TypeNo material change
Effective DateSep 1, 2021
Next Review Date
Key ActionPrior authorization required; initial authorization valid for 12 months (365 days) and may be renewed every 12 months thereafter.
POLICY UPDATE CHANGES
No material clinical or coverage changes noted in this brief.
1Covered ICD-10 diagnosis
575Max billable units per interval
12 moPA duration (initial/renewal)
Coverage Summary
Coverage stance: Covered with criteria for Nexviazyme (avalglucosidase alfa-ngpt) for treatment of late-onset (non-infantile) Pompe disease. Dosing is weight-based: members ≥30 kg receive 20 mg/kg IV every two weeks and members <30 kg receive 40 mg/kg IV every two weeks. Prior authorization is required and initial authorization is valid for 12 months (365 days) with renewal possible every 12 months.