Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Plerixafor (Mozobil) may be considered medically necessary for
ANY
of the following conditions:
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;
or
Compendia Sources
Plerixafor (Mozobil) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of plerixafor (Mozobil) for any other indication listed above is considered experimental/investigational and therefore, not covered. The safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.
Procedure Code
