| Effective Date:06/01/2019 |
Title:Elzonris (tagraxofusperzs)
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| Revision Date:10/01/2019
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Document:BI619:00
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| CPT Code(s):C9049, J9269
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Public Statement
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Effective Date:
a)
This policy
will apply to all services performed on or after the above revision date which
will become the new effective date.
b)
For all
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
1)
Elzonris (tagraxofusp-erzs)
requires prior authorization.
2)
Elzonris is
used to treat a very rare condition known as blastic plasmacytoid dendritic cell
neoplasm (BPDCN).
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Medical Statement
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Elzonris (tagraxofusp-erzs) is considered medically necessary for patients 2
years of age or older with a diagnosis of blastic plasmacytoid dendritic cell
neoplasm (BPDCN).
Codes
Used In This BI:
C9049 Elzonris
J9269
Injection, tagraxofusp-erzs, 10mcg
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Limits
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Intentially left empty
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Reference
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1)
Elzonris
Package Insert. Stemline Therapeutics. December 2018.
2)
Clinical
Pharamcology. Accessed online 04-25-2019.
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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