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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

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

The prescribed regimen must be within the FDA-approved dosing regimen.

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

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
  • 05/2018

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