Ziextenzo (pegfilgrastim-bmez) — Blue Cross Blue Shield of Montana

Preferred products

• Nivestym (filgrastim-aafi)
• Zarxio (filgrastim-sndz)
• Fulphila (pegfilgrastim-jmdb)
• Nyvepria (pegfilgrastim-apgf)

Initial criteria

• Target Agent(s) will be approved when ONE of the following is met:
• 1. BOTH of the following:
• A. ONE of the following:
• 1. The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
• 2. The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes are required] AND
• B. The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration OR
• 2. ONE of the following:
• A. The patient has been treated with the requested agent within the past 90 days OR
• B. The patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent [chart notes are required] OR
• C. The patient has tried and had an inadequate response to ONE corresponding prerequisite agent [chart notes are required] OR
• D. ONE corresponding prerequisite agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required] OR
• E. The patient has an intolerance or hypersensitivity to ONE corresponding prerequisite agent that is not expected to occur with the requested agent [chart notes are required] OR
• F. The patient has an FDA labeled contraindication to ALL corresponding prerequisite agents that is not expected to occur with the requested agent and route of administration [chart notes are required] OR
• G. ONE corresponding prerequisite agent is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm [chart notes are required] OR a prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes are required] OR
• H. ONE corresponding prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes are required] OR
• I. The patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as ONE corresponding prerequisite agent and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes are required]

Approval duration

12 months