Granix (tbo-filgrastim) — CareFirst (Caremark)

Initial criteria

• The requested medication will not be used in combination with other colony stimulating factors within any chemotherapy cycle.
• The member will not receive chemotherapy at the same time as they receive radiation therapy.
• The requested medication will be used for primary prophylaxis in members with solid tumors or non-myeloid malignancies who have received, are currently receiving, or will be receiving any of the following: myelosuppressive anti-cancer therapy expected to result in ≥20% incidence of febrile neutropenia; myelosuppressive anti-cancer therapy expected to result in 10–19% risk of febrile neutropenia and who are high risk because of bone marrow compromise, co-morbidities, or other patient specific risk factors; or myelosuppressive anti-cancer therapy expected to result in <10% risk of febrile neutropenia and who have at least 2 patient-related risk factors.
• OR the requested medication will be used for secondary prophylaxis in members with solid tumors or non-myeloid malignancies who experienced febrile neutropenia or dose-limiting neutropenic event from a prior cycle of similar chemotherapy (for which primary prophylaxis was not received).
• OR the requested medication will be used for treatment of high risk febrile neutropenia in members who have prognostic factors predictive of deterioration, such as age >65 years or being hospitalized at time of fever development.

Approval duration

6 months