Udenyca — 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 criteria is met: The requested medication will be used for primary prophylaxis in members with a solid tumor or non-myeloid malignancies who have received, are currently receiving, or will be receiving any of the following: Myelosuppressive anti-cancer therapy expected to result in ≥ 20% incidence of febrile neutropenia, OR Myelosuppressive anti-cancer therapy expected to result in 10–19% risk of febrile neutropenia and who are considered at high risk because of bone marrow compromise, co-morbidities, or other patient-specific risk factors, OR Myelosuppressive anti-cancer therapy expected to result in <10% risk and who have at least 2 patient-related risk factors
• OR The requested medication will be 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
• Authorization may be granted for other indications including stem cell transplantation-related, hematopoietic subsyndrome of acute radiation syndrome, treatment for radiation-induced myelosuppression following a radiological/nuclear incident, hairy cell leukemia, or members with hairy cell leukemia with neutropenic fever following chemotherapy

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