Does J3060 require prior authorization?

Yes, J3060 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3060?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J3060`, Injection, taliglucerase alfa, 10 units

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Continuation of ERT requires documented positive clinical response, FDA-labeled dosing, and continuation up to 12 months.
Initial authorization duration limited to 12 months.

Key Coverage Criteria

Initial therapy for Type 1 Gaucher disease with Cerezyme, Elelyso, or VPRIV requires: (1) diagnosis of Type 1 Gaucher disease, (2) symptomatic disease, (3) dosing in accordance with FDA labeling, and (4) initial authorization for up to 12 months; continuation requires: (1) documented positive clinical response, (2) dosing in accordance with FDA labeling, and (3) continuation up to 12 months.
Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
Taliglucerase alfa (Elelyso) is covered for individuals ≥4 years with confirmed Type 1 Gaucher disease.
Velaglucerase alpha (VPRIV) is covered for long-term ERT in individuals ≥4 years with Type 1 Gaucher disease.
Vestronidase alfa-vjbk (Mepsevii) is covered for individuals with MPS VII (Sly syndrome).
Agalsidase beta (Fabrazyme) is covered when the member is ≥2 years old and has a confirmed diagnosis of Fabry disease.

20 Active Policies

ARKBLUE-TREATMENT-FOR-GAUCHER-DISEASE-IMIGLUCERASE-E-G-C-02A240C009, Treatment for Gaucher Disease: [Imiglucerase (e.g., Cerezyme), taliglucerase alfa (e.g., Elelyso), and velaglucerase alfa (e.g., Vpriv)]

BCBSM-2132014-B32241ABA0, ELELYSO (TALIGLUCERASE) ENZYME REPLACEMENT THERAPY (J3060) retired as of 10/8/2020

HEALTHPARTNERS-CC-AENTRY-046263, Gaucher disease enzyme replacement therapy: imiglucerase (Cerezyme), velaglucerase (Vpriv), and taliglucerase (Elelyso)

MULTI

POINT32HEALTH-MDMNG-22656, Cerezyme (imiglucerase), Elelyso (taliglucerase alfa), VPRIV velaglucerase alfa)

MULTI

HEALTHNET_OR-HNOR-TALIGLUCERASE-ALFA-ELELYSO-CP-PHAR-157-8273630AD9, Taliglucerase alfa (Elelyso); CP.PHAR.157

MODA-ELELYSO-1EBBB490DA, Elelyso (taliglucerase alfa)

BCBSNM-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care

BCBSOK-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care

UHC-POL-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

BCBSTN-029c647eac, Taliglucerase Alfa (Elelyso)

EVICORE-MEDICAL_DRUG-387E452C5E84, Elelyso (taliglucerase alfa)

UMR-POL-UMR-intravenous-enzyme-replacement-therapy-gaucher-disease, Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

BCBSIL-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care

BCBSMT-RX501.067, Enzyme-Replacement Therapy for Lysosomal Storage Disorders

`J3060`, Injection, taliglucerase alfa, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3060, Injection, taliglucerase alfa, 10 units

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3060`, Injection, taliglucerase alfa, 10 units