Leukine (sargramostim) — 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.
• One of the following criteria is met:
• 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 (FN).
• Myelosuppressive anti-cancer therapy expected to result in 10–19% risk of FN and member is at high risk of FN because of bone marrow compromise, comorbidities, or other patient-specific risk factors.
• Myelosuppressive anti-cancer therapy expected to result in <10% risk of FN and member has 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 a febrile neutropenic complication or dose-limiting neutropenic event from a prior cycle of similar chemotherapy with the same dose/schedule planned for the current cycle for which primary prophylaxis was not received.
• OR The requested medication will be used for treatment of high-risk febrile neutropenia (FN) in members who have any of the following prognostic factors predictive of clinical deterioration: age > 65 years, being hospitalized at time of fever, sepsis syndrome, invasive fungal infection, pneumonia or other clinically documented infection, prolonged (neutropenia expected >10 days) or profound (ANC <0.1 x 10⁹/L) neutropenia, or prior episodes of febrile neutropenia.

Reauthorization criteria

• Member must continue to meet all requirements in the coverage criteria.

Approval duration

6 months