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​​Elzonris®​ and Trogarzo™ policies to be archived

December 6, 2021

Independence will archive four Medical Policies, effective January 3, 2022.

Commercial Medical Policies

Medical Policy #08.01.55c: Tagraxofusp-erzs (Elzonris®):

  • The HCPCS code J9269 Injection, tagraxofusp-erzs, 10 micrograms is eligible for coverage.
  • A Policy Notification was posted December 3, 2021.
Medical Policy #08.01.46a: Ibalizumab-uiyk (Trogarzo™):
  • The HCPCS code J1746 Injection, ibalizumab-uiyk, 10 mg is eligible for coverage.
  • A Policy Notification was posted December 3, 2021.

Medicare Advantage Medical Policies


Medical Policy #MA08.105c: Tagraxofusp-erzs (Elzonris®):
  • The HCPCS code J9269 Injection, tagraxofusp-erzs, 10 micrograms is eligible for coverage.
  • A Policy Notification was posted December 3, 2021.
Medical Policy #MA08.096a: Ibalizumab-uiyk (Trogarzo™):
  • The HCPCS code J1746 Injection, ibalizumab-uiyk, 10 mg is eligible for coverage.
  • A Policy Notification was posted December 3, 2021.

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