Subject: plerixafor-Mozobil 1860-A SGM P2023a

Drug

MOZOBIL  (plerixafor)

plerixafor

Policy:

      I.  INDICATIONS
          The indications below including FDA-approved indications and
          compendial uses are considered a covered benefit provided that
          all the approval criteria are met and the member has no
          exclusions to the prescribed therapy.

          A.  FDA-Approved Indication
               Mozobil is indicated in combination with granulocyte-colony
               stimulating factor (G-CSF) to mobilize hematopoietic stem
               cells (HSCs) to the peripheral blood for collection and
               subsequent autologous transplantation in patients with non-
               Hodgkin’s lymphoma or multiple myeloma.

          B.  Compendial Use
               Hematopoietic cell transplantation

          All other indications are considered experimental/investigational
          and not medically necessary.


    II.  CRITERIA FOR INITIAL APPROVAL
          Hematopoietic Stem Cell Mobilization
          Authorization of 6 months may be granted when all of the
          following criteria are met:
          A.  The requested medication will be used to mobilize
               hematopoietic stem cells for collection prior to
               transplantation.
          B.  The requested medication will be administered after the
               member has received a G-CSF (e.g., filgrastim) or chemo-
               mobilization.
          C.  The requested medication will not be used beyond 4
               consecutive days or after completion of stem cell
               harvest/apheresis.


  III.  CONTINUATION OF THERAPY

          All members (including new members) requesting
          authorization for continuation of therapy must meet all initial
          authorization criteria.

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Mozobil [package insert]. Cambridge, MA: Genzyme Corporation; August 2020.
2. Plerixafor [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals LLC; May 2023.
3. The NCCN Drugs & Biologics Compendium^® © 2023 National Comprehensive Cancer Network, Inc. https://www.nccn.org. Accessed January 5, 2023.
4. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Hematopoietic Cell Transplantation (HCT) Version 2.2022. https://www.nccn.org/professionals/physician_gls/pdf/hct.pdf  Accessed January 5, 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 09, 2023