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Plerixafor (Mozobil)

Section: Injections
Effective Date: December 01, 2019
Revised Date: November 26, 2019

Description

Plerixafor (Mozobil™) is a hematopoietic stem cell mobilizer and inhibitor of the CXCR4 chemokine receptor. CXCR4 is specific for stromal-derived-factor 1 (SDF-1), a molecule endowed with potent chemotactic activity for lymphocytes. Because the interaction between SDF-1 and CXCR4 plays an important role in holding hematopoietic stem cells in the bone marrow, drugs that block the CXCR4 receptor appear to be capable of mobilizing hematopoietic stem cells into the bloodstream.

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.

Plerixafor (Mozobil) may be considered medically necessary for ANY of the following conditions:

Food and Drug Administration (FDA) Indication

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) Indications

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
  • Mobilization of donor hematopoietic progenitor cells in the allogeneic setting.

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, or
  • Mobilization of donor hematopoietic progenitor cells in the allogeneic setting.

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.

Note: Plerixafor is to be prescribed under the supervision of an oncologist/hematologist.

Procedure Codes

J2562

Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

Covered Diagnosis Codes

C56.1 C56.2 C56.9 C62.00 C62.01 C62.02 C62.10
C62.11 C62.12 C62.90 C62.91 C62.92 C81.00 C81.01
C81.02 C81.03 C81.04 C81.05 C81.06 C81.07 C81.08
C81.09 C81.10 C81.11 C81.12 C81.13 C81.14 C81.15
C81.16 C81.17 C81.18 C81.19 C81.20 C81.21 C81.22
C81.23 C81.24 C81.25 C81.26 C81.27 C81.28 C81.29
C81.30 C81.31 C81.32 C81.33 C81.34 C81.35 C81.36
C81.37 C81.38 C81.39 C81.40 C81.41 C81.42 C81.43
C81.44 C81.45 C81.46 C81.47 C81.48 C81.49 C81.70
C81.71 C81.72 C81.73 C81.74 C81.75 C81.76 C81.77
C81.78 C81.79 C81.90 C81.91 C81.92 C81.93 C81.94
C81.95 C81.96 C81.97 C81.98 C81.99 C82.00 C82.01
C82.02 C82.03 C82.04 C82.05 C82.06 C82.07 C82.08
C82.09 C82.10 C82.11 C82.12 C82.13 C82.14 C82.15
C82.16 C82.17 C82.18 C82.19 C82.20 C82.21 C82.22
C82.23 C82.24 C82.25 C82.26 C82.27 C82.28 C82.29
C82.30 C82.31 C82.32 C82.33 C82.34 C82.35 C82.36
C82.37 C82.38 C82.39 C82.40 C82.41 C82.42 C82.43
C82.44 C82.45 C82.46 C82.47 C82.48 C82.49 C82.50
C82.51 C82.52 C82.53 C82.54 C82.55 C82.56 C82.57
C82.58 C82.59 C82.60 C82.61 C82.62 C82.63 C82.64
C82.65 C82.66 C82.67 C82.68 C82.69 C82.80 C82.81
C82.82 C82.83 C82.84 C82.85 C82.86 C82.87 C82.88
C82.89 C82.90 C82.91 C82.92 C82.93 C82.94 C82.95
C82.96 C82.97 C82.98 C82.99 C83.00 C83.01 C83.02
C83.03 C83.04 C83.05 C83.06 C83.07 C83.08 C83.09
C83.10 C83.11 C83.12 C83.13 C83.14 C83.15 C83.16
C83.17 C83.18 C83.19 C83.30 C83.31 C83.32 C83.33
C83.34 C83.35 C83.36 C83.37 C83.38 C83.39 C83.50
C83.51 C83.52 C83.53 C83.54 C83.55 C83.56 C83.57
C83.58 C83.59 C83.70 C83.71 C83.72 C83.73 C83.74
C83.75 C83.76 C83.77 C83.78 C83.79 C83.80 C83.81
C83.82 C83.83 C83.84 C83.85 C83.86 C83.87 C83.88
C83.89 C83.90 C83.91 C83.92 C83.93 C83.94 C83.95
C83.96 C83.97 C83.98 C83.99 C84.00 C84.01 C84.02
C84.03 C84.04 C84.05 C84.06 C84.07 C84.08 C84.09
C84.10 C84.11 C84.12 C84.13 C84.14 C84.15 C84.16
C84.17 C84.18 C84.19 C84.40 C84.41 C84.42 C84.43
C84.44 C84.45 C84.46 C84.47 C84.48 C84.49 C84.60
C84.61 C84.62 C84.63 C84.64 C84.65 C84.66 C84.67
C84.68 C84.69 C84.70 C84.71 C84.72 C84.73 C84.74
C84.75 C84.76 C84.77 C84.78 C84.79 C84.90 C84.91
C84.92 C84.93 C84.94 C84.95 C84.96 C84.97 C84.98
C84.99 C84.A0 C84.A1 C84.A2 C84.A3 C84.A4 C84.A5
C84.A6 C84.A7 C84.A8 C84.A9 C84.Z0 C84.Z1 C84.Z2
C84.Z3 C84.Z4 C84.Z5 C84.Z6 C84.Z7 C84.Z8 C84.Z9
C85.10 C85.11 C85.12 C85.13 C85.14 C85.15 C85.16
C85.17 C85.18 C85.19 C85.20 C85.21 C85.22 C85.23
C85.24 C85.25 C85.26 C85.27 C85.28 C85.29 C85.80
C85.81 C85.82 C85.83 C85.84 C85.85 C85.86 C85.87
C85.88 C85.89 C85.90 C85.91 C85.92 C85.93 C85.94
C85.95 C85.96 C85.97 C85.98 C85.99 C86.0 C86.1
C86.2 C86.3 C86.4 C86.5 C86.6 C88.4 C88.8
C88.9 C90.00 C90.01 C90.02 C90.10 C90.11 C90.12
C90.20 C90.21 C90.22 C90.30 C90.31 C90.32 C91.40
C91.41 C91.42 C91.50 C96.0 C96.20 C96.21 C96.22
C96.29 D47.02 D47.09 C96.4 C96.5 C96.6 C96.9
C96.A C96.Z Z94.84

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