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HealthPartners

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 (Mozobil®) requires prior authorization from HeathPartners Pharmacy Administration.

Coverage

Mozobil is generally covered subject to the indications listed below when all of the following criteria are met, and per member plan documents. All requests for doses exceeding the FDA-approved regimen will not be covered.

Initial Authorizations:

  1. Patient must have non-Hodgkin’s lymphoma and multiple myeloma; and,
  2. Must be 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.

Initial authorizations will be for a maximum of 4 doses

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

Mozobil 24 MG/1.2ML SOLN

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. December 2017.

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Policy activity

  • 04/06/2009 - Date of origin
  • 07/12/2017 - Effective date
Review date
  • 05/2019

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