Neulasta — Cigna

Initial criteria

• Approve for 6 months if the patient meets the following (A and B):
• A) Patient meets ONE of the following (i, ii, or iii):
• i. Patient is receiving myelosuppressive anti-cancer medications that are associated with a high risk of febrile neutropenia (the risk is at least 20% based on the chemotherapy regimen); OR
• ii. Patient meets both of the following (a and b):
• a) Patient is receiving myelosuppressive anti-cancer medications that are associated with a risk of febrile neutropenia, but the risk is less than 20% based on the chemotherapy regimen; AND
• b) Patient has at least one risk factor for febrile neutropenia according to the prescriber;
• Note: Examples of risk factors include age ≥ 65 years; prior chemotherapy or radiation therapy; persistent neutropenia; bone marrow involvement by tumor; recent surgery and/or open wounds; liver and/or renal dysfunction; poor performance status; or human immunodeficiency virus (HIV) infection.
• iii. Patient meets both of the following (a and b):
• a) Patient has had a neutropenic complication from prior chemotherapy and did not receive prophylaxis with a colony stimulating factor; AND
• b) A reduced dose or frequency of chemotherapy may compromise treatment outcome; AND
• B) The medication is prescribed by or in consultation with an oncologist or hematologist.

Approval duration

6 months