Udenyca — CareFirst (Caremark)

Initial criteria

• Requested medication will not be used in combination with other colony stimulating factors within any chemotherapy cycle
• Member will not receive chemotherapy at the same time as radiation therapy
• Requested medication will not be administered with weekly chemotherapy regimens
• For primary prophylaxis: Member has a solid tumor or non-myeloid malignancy receiving myelosuppressive anti-cancer therapy expected to result in ≥20% incidence of febrile neutropenia OR 10–19% risk with high-risk factors (bone marrow compromise, comorbidities, or other patient-specific risk factors) OR <10% risk with at least 2 patient-related risk factors
• For secondary prophylaxis: Member with solid tumor or non-myeloid malignancy has experienced a febrile neutropenic complication or dose-limiting neutropenic event from prior cycle of similar chemotherapy for which primary prophylaxis was not received

Reauthorization criteria

• All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteria

Approval duration

6 months