Neupogen — CareFirst (Caremark)
Chronic Myeloid Leukemia with persistent neutropenia due to tyrosine kinase inhibitor therapy
Initial criteria
- Medication will not be used in combination with other colony stimulating factors within any chemotherapy cycle
- Member will not receive chemotherapy concurrently with radiation therapy
- Primary prophylaxis: member with solid tumor or non-myeloid malignancy receiving myelosuppressive anti-cancer therapy expected to cause ≥20% incidence of febrile neutropenia OR 10–19% risk with high-risk factors (bone marrow compromise, comorbidities, or other patient risk factors) OR <10% risk and at least 2 patient-related risk factors
- Secondary prophylaxis: member with solid tumor or non-myeloid malignancy who experienced febrile neutropenic complication or dose-limiting neutropenic event from a prior chemotherapy cycle when primary prophylaxis was not given
- Treatment of high-risk febrile neutropenia in members with any of the following: age >65 years OR hospitalization at time of fever development
Approval duration
6 months