ELZONRIS (tagraxofusp)

ELZONRIS (tagraxofusp)

MEDICAL BENEFIT - INTRAVENOUS ADMINISTRATION 

Indications for Prior Authorization:

• Indicated in adults and pediatric patients ≥ 2 years of age for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN)

Patients must meet the following criteria for the indication(s) above:

• Patient is ≥ 2 years of age, AND
• Diagnosis of BPDCN confirmed by chart note documentation, AND
• Prescribed by or in consultation with an oncologist or hematologist

Dosing:

• IV: 12 mcg/kg over 15 minutes once daily on days 1 to 5 of a 21-day cycle
• Prior to first dose, ensure that the serum albumin level is ≥ 3.2 g/dL
• Dosing period may be extended for dose delays up to day 10 of the cycle
• Consider pre-treatment with histamine-1 antagonist, histamine-2 antagonist, a corticosteroid, and acetaminophen approximately 1 hour prior to administering Elzonris™

Approval:

• 1 year