Medical Policy

Effective Date:06/01/2019 Title:Elzonris (tagraxofusperzs)
Revision Date:10/01/2019 Document:BI619:00
CPT Code(s):C9049, J9269
Public Statement

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).

Medical Statement

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

Intentially left empty

1)    Elzonris Package Insert. Stemline Therapeutics. December 2018.

2)    Clinical Pharamcology. Accessed online 04-25-2019.

Application to Products
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.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.