928 Form

Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) Prior Authorization Request Form #928

Medical Policy #009 Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN)

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Elzonris (tagraxofusp-erzs) for the Treatment of Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations. Complete Prior Authorization Request Form for Elzonris (928) using Authorization Manager

For out of network providers: Requests should still be faxed to 888-973-0726.

Patient Information Patient Name and DOB:

Today’s Date: BCBSMA ID#:

Date of Treatment:

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

Place of Service: Inpatient  Outpatient 

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  Note: • Initial treatment cycle must be administered in an inpatient setting and individual will be monitored for at least 24 hours after last infusion. • Subsequent treatment cycles may be administered in an appropriate outpatient setting and additional prior authorization is required.

  Please submit clinical documentation to support your request including: • Clinical background with confirmed diagnosis of BPDCN • Current labs, ECOG performance score • Any additional relevant clinical information.