Fylnetra (pegfilgrastim-pbbk) — Blue Cross Blue Shield of Oklahoma

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 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 FDA 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 is currently stable on it [chart notes required] OR
• C. The patient has tried and had an inadequate response to ONE corresponding prerequisite agent [chart notes required] OR
• D. ONE corresponding prerequisite agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event [chart notes required] OR
• E. The patient has an intolerance or hypersensitivity to ONE corresponding prerequisite agent not expected with the requested agent [chart notes required] OR
• F. The patient has an FDA labeled contraindication to ALL corresponding prerequisite agents not expected with the requested agent [chart notes required] OR
• G. ONE corresponding prerequisite agent is expected to be ineffective or cause a significant barrier, worsen a comorbid condition, decrease ability to perform daily activities, cause adverse reaction or harm, or it is not in the best interest of the patient based on medical necessity [chart notes required] OR
• H. ONE corresponding prerequisite agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
• I. The patient has tried another prescription drug in the same pharmacologic class or mechanism as the prerequisite agent and discontinued due to lack of efficacy or adverse event [chart notes required]

Approval duration

12 months