Neulasta — 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 not be administered with weekly chemotherapy regimens.
• One of the following is met:
• - Used for primary prophylaxis in members with a solid tumor or non-myeloid malignancies receiving myelosuppressive anti-cancer therapy that is expected to result in 20% or higher incidence of febrile neutropenia.
• - Used for primary prophylaxis in members with solid tumor or non-myeloid malignancies receiving myelosuppressive anti-cancer therapy that is expected to result in 10–19% risk of febrile neutropenia and who are considered to be at high risk due to bone marrow compromise, comorbidities, or other patient-specific risk factors.
• - Used for primary prophylaxis in members receiving myelosuppressive anti-cancer therapy with <10% risk of febrile neutropenia and who have at least 2 patient-related risk factors.
• - Used for secondary prophylaxis in members with solid tumors or non-myeloid malignancies who experienced a febrile neutropenic complication or a dose-limiting neutropenic event from a prior cycle of similar chemotherapy (for which primary prophylaxis was not received).

Reauthorization criteria

• All members requesting authorization for continuation of therapy must meet all requirements in the coverage criteria.

Approval duration

6 months