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.
The use of tagraxofusp-erzs (Elzonris) for the treatment (e.g., first-line therapy, as treatment induction, continuation after induction, or for relapsed/refractory disease if not already used) of BPDCN may be considered medically necessary when ALL of the following criteria are met:
- Documentation of diagnosis of BPDCN; and
- Medication prescribed by or in consultation with an oncologist or hematologist; and
- Individual is 2 years of age or older; and
- Initial treatment cycle MUST be administered in an inpatient setting and individual will be monitored for at least 24 hours after last infusion:
- Subsequent treatment cycles can be administered in appropriate outpatient setting.
The use of tagraxofusp-erzs (Elzonris) for any other indication is considered experimental/investigational and therefore non-covered as the published peer reviewed literature does not support its efficacy or safety for any other indications.
Procedure Codes
