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Coverage criteria policies

Plerixafor (Mozobil®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Plerixafor requires prior authorization from HeathPartners Pharmacy Administration.

Coverage

Plerixafor will be covered for FDA approved indications and will be reserved for prescribing by specialists.

Indications that are covered

Use in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma and multiple myeloma.

Indications that are not covered

Other conditions not listed in this policy will be reviewed on a case by case basis for medical necessity.

Definitions

Mozobil (plerixafor) is a hematopoietic stem cell mobilizer, indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin’s lymphoma and multiple myeloma.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPC

Code

Description

J2562

Injection, plerixafor, 1 mg

NDC

Codes

Description

00024586201

24mg/1.2 mL single dose vial

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Mozobil prescribing information. Genzyme Corporation. August 2015.
  2. A phase II study of plerixafor (AMD3100) plus G-CSF for autologous hematopoietic progenitor cell mobilization in patients with Hodgkin lymphoma. Cashen A, Lopez S, Gao F, Calandra G, MacFarland R, Badel K, DiPersio J. Biol Blood Marrow Transplant. 2008 Nov;14(11):1253-61.
  3. Rescue from failed growth factor and/or chemotherapy HSC mobilization with G-CSF and plerixafor (AMD3100): an institutional experience. Fowler CJ, Dunn A, Hayes-Lattin B, Hansen K, Hansen L, Lanier K, Nelson V, Kovacsovics T, Leis J, Calandra G, Maziarz RT. Bone Marrow Transplant. 2009 Feb 2.
  4. Treatment with plerixafor in non-Hodgkin's lymphoma and multiple myeloma patients to increase the number of peripheral blood stem cells when given a mobilizing regimen of G-CSF: implications for the heavily pretreated patient. Stiff P, Micallef I, McCarthy P, et al., Biol Blood Marrow Transplant. 2009 Feb; 15(2):249-56.

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Policy activity

  • 04/06/2009 - Date of origin
  • 07/12/2017 - Effective date
Review date
  • 04/2017

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