Releuko — Medica
patient meets the respective standard Colony Stimulating Factors – Filgrastim Products Prior Authorization Policy
Preferred products
- Nivestym
Initial criteria
- Patient meets the respective standard Colony Stimulating Factors – Filgrastim Products Prior Authorization Policy; AND
- Patient has tried Nivestym [documentation required]; AND
- Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction.
Approval duration
as noted in the respective standard Colony Stimulating Factors Prior Authorization Policy