CurrentCignaPolicy N/A

Plerixafor (Mozobil) prior authorization form and coverage criteria

Prior authorization form and requirements for coverage of plerixafor (Mozobil) for stem cell mobilization and other listed indications for Cigna members; intended for prescribers and provider offices requesting coverage/authorization.

Policy Summary

PayerCigna

PolicyPlerixafor (Mozobil) prior authorization form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the form (fax or online) or call the urgent phone number; standard review time is 5 business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5standard response time for prescription drug coverage requests

4maximum consecutive days plerixafor may be given prior to apheresis

24 mg/1.2 mLlisted vial strength for Mozobil

phoneurgent request contact

Coverage Criteria for Plerixafor (Mozobil)

Mobilization and indication criteria

Covered when ALL of the following are met (as documented on the form):

specialist involvement: For MM, NHL, or Hematopoietic Stem Cell Donor indications, the medication is prescribed by or in consultation with a hematologist or a stem cell transplant physician.

checkbox on form

indication selection: Diagnosis/indication selected on the form (e.g., Multiple Myeloma, Non-Hodgkin's Lymphoma, Leukemia, Hematopoietic Stem Cell Donor for autologous or allogeneic transplant, WHIM syndrome, or other).

checkboxed diagnosis on form

mobilization intent for MM/NHL or donors: If for MM or NHL, the drug is being used for mobilization of hematopoietic stem cells for subsequent autologous transplantation; if for a Hematopoietic Stem Cell Donor, the form documents whether the mobilization is for autologous or allogeneic transplantation.

Policy Summary

PayerCigna

PolicyPlerixafor (Mozobil) prior authorization form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization using the form (fax or online) or call the urgent phone number; standard review time is 5 business days.

SourceLink

On This Page

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form-specific checkboxes

concomitant colony-stimulating factor and timing: Medication will be used in combination with a granulocyte-colony stimulating factor (G-CSF/CSF) as documented, with the patient having received (or planned to receive) a colony-stimulating factor for 4 days prior to plerixafor and plerixafor given approximately 11 hours prior to each apheresis for up to 4 consecutive days.4 days; up to 4 plerixafor doses

dosing schedule specified on form

The prior authorization form does not list any explicit exclusions by diagnosis. Instead, it provides a discrete checkbox list for specific indications (Hematopoietic Stem Cell Donors, Leukemia, Multiple Myeloma, Non-Hodgkin's lymphoma, WHIM syndrome) and includes a catch-all option labeled All other indications. When a diagnosis outside the listed options is selected, clinical justification must be documented on the form under that All other indications selection.

The form does not present any explicit not medically necessary conditions. Coverage determinations instead depend on the information provided on the form; lack of required documentation—such as a clearly selected indication or other requested clinical details—may lead to denial or incomplete review. Providers should ensure all relevant fields are completed to support medical necessity.

Regimen	Indication	Notes
G-CSF for 4 days followed by plerixafor administered approximately 11 hours prior to each apheresis
Stem cell mobilization for autologous or allogeneic transplantation (MM, NHL, hematopoietic stem cell donors)
Plerixafor may be given for up to 4 consecutive days; G-CSF/CSF must be given for 4 days prior to first plerixafor dose

Medication Strengths and Related Coding

Medication strengths listedNDC|description

24 mg/1.2 mL (20 mg/mL)

Mozobil vial strength as listed on form

G-CSF days prior to plerixafor

Required G-CSF durationPatient must receive (or will receive) a granulocyte-colony stimulating factor (G-CSF/CSF) for 4 days prior to administration of plerixafor.

Applicable indications on formThis 4-day G-CSF prerequisite is specified for multiple myeloma (MM), non-Hodgkin lymphoma (NHL), and hematopoietic stem cell donor mobilization indications.

Documentation checkboxForm includes explicit yes/no checkboxes confirming that the patient has received or will receive G-CSF for 4 days prior to plerixafor.

Related agents exampleForm references filgrastim products (e.g., Granix, Neupogen), pegfilgrastim (Neulasta), and sargramostim (Leukine) as examples of colony-stimulating factors to be used for the 4-day regimen.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Submission and Timing

Prior Authorization Required. A completed prior authorization form must be submitted before medication is dispensed. Fax completed form to: (855) 840-1678. Save time by submitting online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. If this is an URGENT request, CALL (800) 882-4462 (800.88.CIGNA) to expedite. Our standard response time for prescription drug coverage requests is 5 business days.

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
EHR: Submit via SureScripts
Standard review time: 5 business days
Urgent requests: call (800) 882-4462

Documentation Required

Specialist Attestation

Specialist attestation is required for requests for Multiple Myeloma (MM), Non-Hodgkin's lymphoma (NHL), or Hematopoietic Stem Cell Donors. The form asks whether the medication is being prescribed by or in consultation with a hematologist or a stem cell transplant physician; the prescriber must indicate Yes or No. Prescriber signature and date are required on the attestation section of the form.

Form question: "Is the requested medication being prescribed by (or in consultation with) a hematologist or a stem cell transplant physician?"
Prescriber must sign Attestation and date the form

Documentation Required

Required Documentation on Form

The prior authorization form must include complete patient and prescriber information and clinical details. Required fields (asterisked on the form) include: Physician name and specialty; DEA, NPI or TIN; office contact, phone and fax; patient name, Cigna ID, date of birth, address, and phone. Medication request fields must specify product (Mozobil/plerixafor or other), directions, dose, quantity, duration, ICD-10 diagnosis code, and patient weight. Diagnosis selection (MM, NHL, Leukemia, WHIM syndrome, Hematopoietic Stem Cell Donor, or other) and relevant treatment history/clinical information must be completed.

Patient and prescriber identifiers: Physician name, specialty, DEA/NPI/TIN, office contact, phone, fax
Patient identifiers: Name, Cigna ID, DOB, address, phone
Medication fields: product selection, directions, dose, quantity, duration, ICD-10
Clinical fields: patient weight (kg); diagnosis selection and clinical history

Documentation Required

G-CSF/CSF Prerequisite for Mobilization

For mobilization indications (MM, NHL, or donors), documentation that a granulocyte-colony stimulating factor (G-CSF) or colony stimulating factor (CSF) will be given is required. The form asks that the patient receive G-CSF/CSF for 4 days prior to plerixafor administration (plerixafor is typically given ~11 hours before each apheresis) and confirms whether G-CSF/CSF will be used in combination. For autologous or allogeneic donor mobilization the form includes specific questions about combination with filgrastim or other CSFs and whether the CSF will be given for 4 days prior.

For MM or NHL mobilization: confirm G-CSF given for 4 days prior to plerixafor and that plerixafor will be given ~11 hours before each apheresis (up to 4 days)
For donors (autologous/allogeneic): confirm CSF/filgrastim use and 4-day CSF prior to plerixafor

Covered Mobilization Regimens

Mobilization Regimen	Duration / Timing	Required Concomitant Therapy
G-CSF for 4 days followed by plerixafor approximately 11 hours before initiation of each apheresis
Plerixafor dosing may be given for up to 4 consecutive days
Colony-stimulating factor (e.g., filgrastim, pegfilgrastim, sargramostim) given for 4 days prior to plerixafor; used in combination for mobilization

Line of Therapy / Salvage Indication

salvage

use for mobilization (salvage): Used for mobilization of hematopoietic stem cells for subsequent autologous transplantation (MM/NHL) or for hematopoietic stem cell donors as indicated on the form.

form-specific

Definitions and Mobilization Protocol

Plerixafor mobilization protocol

G-CSF then plerixafor sequenceMobilization regimen: administer G-CSF/CSF for 4 days, then give plerixafor subcutaneously approximately 11 hours prior to initiation of each apheresis.

Maximum consecutive daysPlerixafor may be given prior to apheresis for up to 4 consecutive days as specified on the form.

Indication-specific useRegimen is described for MM or NHL mobilization and for hematopoietic stem cell donors (autologous or allogeneic) when used with a CSF/filgrastim.

Form confirmationThe form contains checkboxes to confirm timing: receipt (or planned receipt) of 4 days of CSF and that plerixafor will be given ~11 hours before each apheresis.

Background

Plerixafor (Mozobil) is presented on the form for use in mobilizing hematopoietic stem cells for collection prior to transplantation and for other listed indications. The form identifies specific diagnostic categories for which mobilization may be requested, and includes an option for All other indications when appropriate clinical justification exists.