Releuko (filgrastim-ayow) — CareFirst (Caremark)

Aplastic anemia

Preferred products

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:
i. Used for primary prophylaxis in members with solid tumors or non-myeloid malignancies who have received, are currently receiving, or will be receiving:
a. Myelosuppressive anti-cancer therapy expected to result in ≥20% incidence of febrile neutropenia (FN)
b. Myelosuppressive anti-cancer therapy expected to result in 10–19% risk of FN and who are at high risk of FN because of bone marrow compromise, co‑morbidities, or other patient-specific risk factors
c. Myelosuppressive anti-cancer therapy expected to result in <10% risk of FN and who have at least 2 patient-related risk factors
ii. 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)
iii. Used for treatment of high-risk febrile neutropenia in members with any of the following prognostic factors predictive of clinical deterioration: age >65 years OR being hospitalized at the time of fever development

6 months