Releuko — 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:
• i. Primary prophylaxis in members with solid tumors or non-myeloid malignancies who have received, are currently receiving, or will be receiving myelosuppressive anti-cancer therapy that is expected to result in ≥ 20% incidence of febrile neutropenia (FN); OR
• ii. Myelosuppressive anti-cancer therapy expected to result in 10–19% risk of FN and member is considered high risk because of bone marrow compromise, co-morbidities, or other patient-specific risk factors; OR
• iii. Myelosuppressive anti-cancer therapy expected to result in <10% risk of FN and member has ≥ 2 patient-related risk factors.
• ii. 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 (for which primary prophylaxis was not received).
• iii. Treatment of high-risk febrile neutropenia in members who have any of the following prognostic factors predictive of clinical deterioration: age > 65 years OR hospitalized at time of fever development.

Approval duration

6 months