Medicare AdvantagePrior AuthMedium impact
Elzonris™ (tagraxofusp-erzs) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Elzonris (tagraxofusp-erzs) prior authorization policy for Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) treatment, effective January 1, 2023, with the most recent revision dated January 28, 2026. The policy requires prior authorization for all Elzonris intravenous infusions and mandates that patients meet three criteria: confirmed BPDCN diagnosis per WHO classification, ability to remain inpatient for the complete first course of therapy plus 24 hours observation, and age 2 years or older. The policy applies to Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina).
Action Required
By January 28, 2026 (revision date): Billing and clinical teams must implement the following: (1) Ensure all Elzonris requests include prior authorization submission before dispensing; (2) Verify patient meets all three coverage criteria at time of authorization—documented BPDCN diagnosis (WHO classification), inpatient capability for full first course plus 24-hour observation, and patient age ≥2 years; (3) Update billing system workflow to flag Elzonris claims requiring prior auth for Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid; (4) Configure authorization duration settings to initial 6 months with 6-month renewal cycle; (5) Educate providers that subsequent cycles may be administered in outpatient ambulatory care with appropriate monitoring, but first cycle must be inpatient; (6) Alert clinical reviewers to monitor for Black Box Warning conditions (Capillary Leak Syndrome, hypersensitivity, hepatotoxicity). Obtain prior authorization via Humana's PAL system for medically billed requests. Failure to obtain prior authorization will result in claim denials.