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Patient Assistance Program
If your patient does not have insurance, or their insurance has denied coverage for Cerezyme, they may be eligible to receive Cerezyme through the Patient Assistance Program (PAP), where free product is provided through Sanofi Cares North America. To see if your patient qualifies, you will need to initiate a CareConnect PAP application. This can be done on paper or online, call the team at 1-800-745-4447, opt. 3, to learn how.
Billing and reimbursement
To bill for Cerezyme therapy, you must use the appropriate codes. The billing procedures may vary according to the site of service or third-party payer guidelines. Please reference this site or call a Sanofi Case Manager for updated billing codes.
In addition to the reimbursement expertise provided by our Sanofi Case Managers, Sanofi also offers a Guide to Cerezyme Billing and Reimbursement to help you through the process.
Cerezyme billing codes
| ICD-10-CM | E75.22 | Lipidosis (Gaucher Disease) |
| NDC | 58468-4663-1 | 400 unit vial |
| HCPCS | J1786 | Cerezyme® - injection, imiglucerase, 10 units |
| CPT-4 | 96365 96366 | Intravenous infusion therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Each additional hour (List separately in addition to primary procedure code, 96365) |
| Revenue | 260 261 258 636 | General IV therapy service Infusion pump IV solutions Drugs and biologicals requiring a HCPCS code |
The unique J-code assigned to Cerezyme, significantly streamlines the reimbursement process. Cerezyme is eligible for reimbursement by commercial payers and Medicare. However, specific policies vary across insurers and from plan to plan.
Providers are responsible for the selection of appropriate codes. Information in the table above provides a general framework for understanding possible coding alternatives. It should not be used as a substitute for a healthcare professional’s own judgment. Any specific guidance or direction regarding claims submission offered by the payer supersedes the information below.
Since third party payers evaluate treatment based on medical necessity, expected outcome, and cost, they generally require documentation of diagnosis and clinical symptoms of Gaucher disease type 1. Refer to the Statement of Medical Necessity sample. This information may need to be submitted with the claim; for specific requirements, check with the payer or contact your Sanofi Case Manager.
To help avoid potential problems obtaining reimbursement, the treating physician should request written confirmation of coverage from the third party payer prior to initiation of enzyme replacement therapy. Sanofi Case Managers can assist in obtaining written authorization for Cerezyme treatment.
For more information, contact Sanofi Support Services at 1‑800‑745‑4447, option 3.
