Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Plerixafor (Mozobil) may be considered medically necessary for ANY ofthe following conditions:
Food and Drug Administration (FDA) Indications
Multiple Myeloma or Non-Hodgkin's Lymphoma
- Used in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation.
National Comprehensive Cancer Network (NCCN) Recommendations
Myeloid Growth Factors
Used in hematopoietic cell transplant for:
- Mobilization of hematopoietic progenitor cells in combination with filgrastim, filgrastim-sndz, or tbo-filgrastim in the autologous setting for individuals with non-Hodgkin lymphoma or multiple myeloma, or
Management of Neutropenia
Used in hematopoietic cell transplant for:
- Mobilization of hematopoietic progenitor cells in combination with filgrastim, filgrastim-aafi, filgrastim-sndz, or tbo-filgrastim in the autologous setting for individuals with non-Hodgkin lymphoma or multiple myeloma.
The use of perixafor (Mozobil) for any diagnosis not listed on this policy is considered experimental/investigational due to lack of scientific-based evidence, and therefore, not covered.
Procedure Codes