CurrentCignaPolicy IP0139

Hematology - Plerixafor

Defines prior authorization, coverage criteria, dosing, and allowed indications for plerixafor (Mozobil) for stem cell mobilization in patients undergoing autologous or allogeneic transplantation and for hematopoietic stem cell donors; applies to Cigna-administered health benefit plans and prescribers specializing in hematology or stem cell transplant.

Policy Summary

PayerCigna

PolicyHematology - Plerixafor

Policy CodePolicy IP0139

Change TypeMultiple material updates

Effective DateNov 15, 2025

Next Review Date

Key ActionObtain prior authorization and ensure the medication is prescribed by a hematologist or stem cell transplant physician.

SourceLink

POLICY UPDATE CHANGES

Policy name updated to 'Hematology - Plerixafor' and explicit requirement added that the medication be prescribed by a hematologist or stem cell transplant physician for multiple myeloma and non-Hodgkin's lymphoma indications.

Hematopoietic Stem Cell Donors added as an approved condition with dosing.

Dosing regimens for patients ≤83 kg and >83 kg (fixed 20 mg or 0.24 mg/kg up to 40 mg) explicitly specified for approved indications.

WHIM syndrome added to Conditions Not Covered (insufficient data).

3Approved indication groups

1 (J2562)Covered HCPCS codes

Up to 4Max consecutive dosing days

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Coverage Criteria for Plerixafor (Mozobil)

FDA-Approved Indications

Covered when ALL of the following are met for each FDA-approved indication listed below:

Multiple Myeloma (Approve for 1 month): A) The agent is utilized for mobilization of hematopoietic stem cells for subsequent autologous transplantation; AND B) Use is in combination with a granulocyte-colony stimulating factor; AND C) The medication is prescribed by a hematologist or a stem cell transplant physician.duration: 1 month

Non-Hodgkin's Lymphoma (Approve for 1 month): A) The agent is utilized for mobilization of hematopoietic stem cells for subsequent autologous transplantation; AND B) Use is in combination with a granulocyte-colony stimulating factor; AND C) The medication is prescribed by a hematologist or a stem cell transplant physician.duration: 1 month

Other Uses with Supportive Evidence

Covered when BOTH conditions are met for hematopoietic stem cell donors:

Hematopoietic Stem Cell Donors (Approve for 1 month): A) Patient meets ONE of the following: i) Patient meets both (a and b): a) The agent is utilized for mobilization of hematopoietic stem cells for subsequent autologous transplantation AND b) Use is in combination with a colony stimulating factor; OR ii) Patient meets both (a and b): a) The agent is utilized for mobilization of hematopoietic stem cells for subsequent allogeneic transplantation AND b) Use is in combination with filgrastim; AND B) The medication is prescribed by a hematologist or a stem cell transplant physician.duration: 1 month

Dosing

Dosing is approved when given after 4 days of colony stimulating factor and administered approximately 11 hours prior to each apheresis for up to 4 consecutive days:

Weight-based dosing options: A) For patients ≤ 83 kg: give by subcutaneous injection a 20 mg fixed dose or 0.24 mg/kg once daily; OR B) For patients > 83 kg: give by subcutaneous injection 0.24 mg/kg up to 40 mg/day once daily.up to 4 consecutive days; administer approximately 11 hours prior to each apheresis after 4 days of colony stimulating factor

Any use of plerixafor (Mozobil) that is not described in the approved indications or the donor-use criteria in this policy is considered experimental, investigational, or unproven and is not covered. The policy specifically identifies the following conditions as not covered: leukemia and WHIM syndrome.

Plerixafor is not covered for use in patients with leukemia because it may cause mobilization of leukemia cells, creating a risk of contamination of the collected apheresis product and subsequent transplantation. Use in WHIM syndrome is not covered due to insufficient data supporting benefit; available trials did not demonstrate superiority over granulocyte-colony stimulating factor for the primary infection-related endpoint and further study is required.

Coding and Minimum Collection Targets

Covered HCPCS CodesHCPCSCovered

J2562

Injection, plerixafor, 1 mg

Minimum recommended stem cell dose for ASCT

Minimum recommended dose2 x 10^6 CD34+ cells/kg (minimum)

Target collection goal3 to 5 x 10^6 CD34+ cells/kg

Context/sourceConsensus guidelines for autologous stem cell mobilization (ASCT)

Prior Authorization, Prescribing, and Billing Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for benefit coverage of plerixafor; approval is recommended when the patient meets the listed clinical criteria and dosing for the FDA‑approved indications or donor use. Extended approvals are allowed if criteria continue to be met; all approvals are provided for the duration noted (1 month = 30 days).

Step Therapy

Use only with G‑CSF after 4 days

Plerixafor must be used in combination with a granulocyte‑colony stimulating factor (examples: filgrastim products such as Granix and Neupogen) after the patient has received G‑CSF for 4 days; plerixafor is given approximately 11 hours prior to each apheresis for up to 4 consecutive days.

Note

Prescriber must be hematologist or transplant physician

Background

Plerixafor is a CXCR4 antagonist that functions as a hematopoietic stem cell mobilizer when given in combination with a granulocyte-colony stimulating factor (G-CSF). By inhibiting CXCR4-mediated retention of hematopoietic stem and progenitor cells in the bone marrow, plerixafor facilitates their movement into the peripheral blood where they can be collected by apheresis for subsequent autologous or allogeneic transplantation.

Definitions

ASCT 6 Definition and collection targets

Definition of ASCTAutologous stem cell transplantation: collection of a patient’s hematopoietic stem and progenitor cells for subsequent reinfusion during autologous transplantation.

Collection targetRecommended stem cell collection target is 3 to 5 x 10^6 CD34+ cells/kg (minimum 2 x 10^6 CD34+ cells/kg).