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 two (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;
or
Compendia Sources
Tagraxofusp-erzs (Elzonris may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of tagraxofusp-erzs (Elzonris) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
