CurrentCentenePolicy CP.PHAR.323

Clinical Policy: Plerixafor (Mozobil)

Covers medical necessity and authorization criteria for plerixafor (Mozobil) used with G-CSF to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with non-Hodgkin lymphoma or multiple myeloma; applies to Centene-affiliated health plans and specified lines of business.

Policy Summary

PayerCentene

PolicyClinical Policy: Plerixafor (Mozobil)

Policy CodePolicy CP.PHAR.323

Change TypeNo material changes

Effective DateMar 1, 2017

Next Review Date

Key ActionPrior authorization is required; submit documentation showing member meets all initial approval criteria and initial approval duration is 3 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NHL, MMDiagnoses covered

up to 4Max consecutive days

40 mg/dayMax dose

J2562HCPCS code

3 monthsInitial auth length

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.

Coverage and Medical Necessity Criteria

Initial Approval Criteria

Covered when ALL of the following are met

Initial Approval - All criteria: 1) Diagnosis of non-Hodgkin lymphoma (NHL) OR multiple myeloma (MM);

Mobilization indication: 2) Indication is mobilization of hematopoietic stem cells (HSCs) for collection and subsequent autologous transplantation;

Prescriber: 3) Prescribed by or in consultation with an oncologist or hematologist;

Brand/generic: 4) If request is for brand Mozobil, member must use generic plerixafor unless contraindicated or clinically significant adverse effects are experienced;

Age: 5) Age ≥ 18 years;

Combination therapy: 6) Prescribed in combination with a formulary granulocyte‑colony stimulating factor (G‑CSF) (e.g., Zarxio);

Transplant plan: 7) Member is scheduled to receive autologous stem cell transplantation;

Duration of administration: 8) Mozobil is prescribed to be administered for up to 4 consecutive days;

Initiate after 4 days of daily G‑CSF and administer approximately 11 hours prior to each apheresis for up to 4 consecutive days.

Dose limits: 9) Dose does not exceed weight‑based dosing: weight < 83 kg: 20 mg/day fixed dose or 0.24 mg/kg/day; weight ≥ 83 kg: 0.24 mg/kg/day up to a maximum of 40 mg/day;

Weight documentation: 10) Documentation of member's current weight (kg) provided.

Requests for coverage of non‑FDA‑approved indications for plerixafor (Mozobil) are not authorized under this policy unless the provider submits sufficient documentation of efficacy and safety in accordance with the applicable off‑label use policy (see CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid) or the member's evidence of coverage documents.

When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid coverage provisions take precedence. Providers should refer to the applicable state Medicaid manual for specific coverage requirements that supersede this policy.

Re‑authorization for continued therapy with plerixafor is not permitted. Any subsequent request for coverage must demonstrate that the member meets the initial approval criteria described in this policy.

Dosing and Administration Regimens

Regimen	Dosing / Administration
Plerixafor administered after 4 days of daily G-CSF, given approximately 11 hours prior to each apheresis for up to 4 consecutive days.
Weight‑based dosing: weight <83 kg: 20 mg fixed dose or 0.24 mg/kg/day; weight ≥83 kg: 0.24 mg/kg/day (maximum 40 mg/day). Administer subcutaneously using actual body weight to calculate volume (0.012 mL × weight in kg).

Billing and Code References

HCPCS CodesHCPCS

J2562

Injection, plerixafor, 1 mg

Weight-based dosing cutoff — 83 kg

Weight cutoff83 kg

Weight <83 kg dosing20 mg fixed dose OR 0.24 mg/kg/day

Weight ≥83 kg dosing0.24 mg/kg/day up to 40 mg/day

Maximum dose40 mg/day

Documentation requirementProvider must document member's current weight (kg)

Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required. This clinical policy guides medical necessity determinations used to assist coverage decisions and administering benefits; the Health Plan or specific benefit designs may require prior authorization for plerixafor and/or the concomitant G‑CSF product.

Prior authorization may be required for G‑CSF when used in combination with plerixafor.

Denial Risk

Denial Risk from Coverage Document Nonconformity

Coverage decisions and the administration of benefits are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance). Requests that are inconsistent with those documents may be denied.

Clinical Background

Plerixafor (Mozobil) is a hematopoietic stem cell mobilizer used in combination with a granulocyte‑colony stimulating factor (e.g., filgrastim) to mobilize hematopoietic stem cells (HSCs) into the peripheral blood for collection and subsequent autologous transplantation. Per prescribing guidance in this policy, treatment is initiated after 4 days of daily G‑CSF and administered approximately 11 hours prior to each apheresis for up to 4 consecutive days. Dosing is weight‑based with a maximum of 40 mg/day.

Key Definitions

granulocyte-colony stimulating factor — G-CSF

TermGranulocyte‑colony stimulating factor (G‑CSF)

Role in therapyUsed in combination with plerixafor to mobilize hematopoietic stem cells to peripheral blood prior to apheresis

Administration timingG‑CSF is given once daily for 4 days before initiating plerixafor

ExamplesFormulary G‑CSF example referenced: Zarxio

hematopoietic stem cells — HSCs

TermHematopoietic stem cells (HSCs)

Purpose

Intended Line of Therapy

salvage

Use prior to autologous transplant: Used to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation; must be scheduled to receive autologous stem cell transplant.