Taliglucerase Alfa (Elelyso®)

Before October 31, 2026: (1) Billing and prior authorization teams must configure the practice management system to require prior authorization for all Taliglucerase Alfa (Elelyso®) claims for Gaucher disease diagnoses. (2) Create or update prior authorization request templates to require submission of: (a) Beta-glucocerebrosidase enzyme assay or genetic testing results, and (b) chart notes documenting baseline clinical signs/symptoms (bone disease, splenomegaly, hepatomegaly, or cytopenia). (3) For continuation authorizations, ensure templates require documentation of therapeutic benefit (improvement in organ volumes, hemoglobin, or platelet counts). (4) Verify that prescribing providers are specialists in metabolic disease or lysosomal storage disorders; flag non-specialist submissions for denial. (5) Update internal billing guidelines to reflect the 60 Units/kg IV every 2 weeks dosing limit. (6) Providers should note this policy applies only to BlueCross BlueShield of Tennessee members; verify patient plan before applying these requirements. Failure to obtain prior authorization per this policy will result in claim denials effective 10/31/26.