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Rolvedon — Medica

any indication meeting the respective standard Colony Stimulating Factors – Rolvedon Prior Authorization Policy

Preferred products

  • Fulphila
  • Ziextenzo

Initial criteria

  • Patient meets the standard Colony Stimulating Factors – Rolvedon Prior Authorization Policy criteria; AND
  • Patient has tried at least one of the following: Fulphila or Ziextenzo [documentation required]
  • Note: A previous trial of any pegfilgrastim product (Neulasta, biosimilars) also satisfies this requirement [documentation required]