CurrentAvMedPolicy Pub. 100-2

Plerixafor (Mozobil) prior authorization for HSC collection

This document governs prior authorization and step-edit requests for plerixafor (Mozobil) used to mobilize hematopoietic stem cells for autologous transplantation for AvMed members. It defines required provider attestation, clinical criteria, dosing limits, and documentation to obtain approval.

Policy Summary

PayerAvMed

PolicyPlerixafor (Mozobil) prior authorization for HSC collection

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign the prior authorization request and provide required documentation including planned transplant date, dosing schedule, weight, and supporting chart notes and labs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 cycleinitial authorization length

4 daysmax days/cycle

40 mgmax daily dose

8 vialsqty limit (24 mg vial)

≥18member age

Coverage Criteria for Plerixafor (Mozobil)

Policy Summary

PayerAvMed

PolicyPlerixafor (Mozobil) prior authorization for HSC collection

Policy CodePolicy Pub. 100-2

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Authorization — Covered when ALL required criteria are met

Covered when ALL of the following are met:

Initial Authorization Criteria: Member is 18 years of age or older; prescribed by or in consultation with a hematologist/oncologist; diagnosis of non-Hodgkin's lymphoma (NHL) or multiple myeloma; intended use is hematopoietic stem cell (HSC) collection for subsequent autologous transplantation; planned date of transplant provided; plerixafor to begin after the member has received granulocyte colony-stimulating factor (G-CSF) such as filgrastim for 4 days (submit recent chart notes/progress notes documenting the planned G-CSF regimen); plerixafor, filgrastim, and apheresis will be continued up to a maximum of 4 days (submit chart notes/progress notes); provider will adhere to recommended weight-based dosing (patients ≤83 kg: 20 mg fixed dose or 0.24 mg/kg once daily for up to 4 days; patients >83 kg: 0.24 mg/kg once daily for up to 4 days, maximum 40 mg daily).see node text

Prescribing physician signature and supporting documentation (member and prescriber information, drug form/strength, dosing schedule, length of therapy, diagnosis/ICD code, weight, planned transplant date, chart notes/progress notes, and relevant labs/diagnostics) must be provided; use of samples to initiate therapy does not meet step-edit/preauthorization criteria.

Reauthorization — Covered when ALL required criteria are met

Reauthorization criteria — Covered when ALL of the following are met:

Reauthorization Criteria: Member continues to meet the diagnosis and dosing requirements from the initial authorization; member is not experiencing unacceptable toxicity from plerixafor (examples include severe hypersensitivity/anaphylaxis; hematologic effects such as leukocytosis or thrombocytopenia; splenic enlargement or rupture; tumor cell mobilization); patient has had only one previous treatment cycle for the planned transplant (reauthorization limited to one additional cycle).see node text

Documentation including lab results, diagnostics, and chart notes/progress notes must be provided to support ongoing appropriateness or request may be denied.

Use of samples to initiate therapy does not meet step-edit or preauthorization criteria.

Requests that do not meet ALL initial or reauthorization criteria, or that lack required documentation (including lab results, diagnostics, and chart notes), may be denied as not medically necessary.

Provider Actions and Prior Authorization Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for plerixafor (J2562). The prescribing physician must sign and clearly print their name on the request (preprinted stamps not valid). Fax completed forms to 1-877-535-1391. Incomplete, incorrect, or illegible information may delay or result in denial of authorization.

Drug: plerixafor (Mozobil) — HCPCS J2562
Fax: 1-877-535-1391
Prescriber signature required (no preprinted stamps)
For Medicare members, comply with Pub. 100-2 Chapter 15 §50 and applicable NCDs/LCDs: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Step Therapy

Step-Therapy Requirement

Plerixafor is subject to a step-therapy requirement: therapy must begin only after the member has received granulocyte colony-stimulating factor (G-CSF) such as filgrastim for 4 days. Use of samples to initiate therapy does not meet the step-edit requirement. Prior G‑CSF use will be verified via pharmacy paid claims or submitted chart notes.

Step requirement: 4 days of G‑CSF (e.g., filgrastim) before plerixafor
Samples do NOT satisfy step-edit/PA criteria
Verification via pharmacy claims or chart notes

Documentation Required

Required Documentation and Signature

Provide all required documentation to support the request. This includes member and prescriber information, diagnosis, intended use (HSC collection for autologous transplant), planned transplant date (if applicable), drug formulation/strength, weight-based dosing schedule and planned therapy length, supporting chart notes/progress notes detailing prior G‑CSF regimen and concurrent/planned apheresis, and relevant labs. The prescribing physician’s signature must be present.

Member/prescriber name, contact, and identifiers
Diagnosis: non‑Hodgkin lymphoma or multiple myeloma
Intended use: HSC collection for autologous transplantation; Planned transplant date
Drug form/strength and dosing: weight-based dosing with limits (≤83 kg: 20 mg fixed or 0.24 mg/kg daily; >83 kg: 0.24 mg/kg daily up to 40 mg; up to 4 consecutive days)
Planned therapy length: Initial authorization = 1 treatment cycle, max 4 days; Reauthorization = 1 cycle, max 4 days
Documentation of 4 days of prior G‑CSF and plan to continue plerixafor, filgrastim, and apheresis up to 4 days (submit chart/progress notes)
Relevant labs and any evidence of unacceptable toxicity if applicable
Prescriber signature (hand-signed; no preprinted stamps)

Denial Risk

Incomplete Documentation Risks Denial

Failure to provide complete, legible, and accurate documentation — including missing signature, absent verification of prior 4 days G‑CSF, missing chart notes, or missing labs — may delay review or result in denial of the request.

Incomplete/illegible forms or missing prescriber signature may delay or cause denial
Lack of documentation verifying 4 days of prior G‑CSF or reliance on samples risks denial
Missing labs, chart notes, or dosing information may result in denial

Regimen	Dosing / Limits	Administration / Duration
Plerixafor administered following 4 days of G‑CSF (e.g., filgrastim)	Patients ≤83 kg: 20 mg fixed dose or 0.24 mg/kg once daily; Patients >83 kg: 0.24 mg/kg once daily (maximum 40 mg daily)	Plerixafor is given with concurrent filgrastim and apheresis may continue up to a maximum of 4 consecutive days (one treatment cycle)

Background

Plerixafor (Mozobil) is used to mobilize hematopoietic stem cells (HSCs) into the peripheral blood for collection prior to autologous transplantation in patients with multiple myeloma or non-Hodgkin's lymphoma. Per the authorization form, plerixafor is administered only after a course of granulocyte colony-stimulating factor (G-CSF) such as filgrastim for 4 days and is given concurrently with filgrastim and apheresis for up to 4 days to facilitate HSC collection. Weight‑based dosing and maximum daily dose limits (see dosing criteria) apply, and documentation of the planned transplant date and supporting chart notes is required to support the clinical indication.

J2562	plerixafor, Mozobil
HCPCS unit	plerixafor injection, 1 mg = 1 billable unit

OpenPayer

Plerixafor (Mozobil) prior authorization for HSC collection

Coverage Criteria for Plerixafor (Mozobil)

Billing and Coding

Provider Actions and Prior Authorization Instructions

Covered Regimens and Dosing

Line of Therapy

Definitions

Background