Tagraxofusp-erzs (Elzonris™) is a first in class CD123-directed cytotoxin composed of recombinant human interleukin-3 and truncated diphtheria toxin fusion protein that inhibits protein synthesis for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in individuals 2 years of age and older.
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 of BPDCN may be considered medically necessary when ALL of the following criteria are met:
The use of tagraxofusp-erzs (Elzonris) for any other indication is considered experimental/investigational as the published peer reviewed literature does not support its efficacy or safety for any other indications.
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.