Fylnetra — Medical Mutual

Preferred products

• Neulasta
• Fulphila

Initial criteria

• If the request is for Nyvepria, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon, Ryzneuta, or pegfilgrastim-fpgk, the patient had an inadequate response, or has a contraindication or intolerance to Neulasta or Fulphila; AND
• Patient is at least age ≥ 18 years (Rolvedon and Ryzneuta ONLY); AND
• For prophylactic use in patients with solid tumors or non-myeloid malignancy: Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia >20%; OR
• Expected incidence of febrile neutropenia 10%-20% AND at least one patient-related risk factor; OR
• Expected incidence of febrile neutropenia <10% AND at least two patient-related risk factors
• For Wilms Tumor: Patient has favorable histology disease; AND used in combination with a cyclophosphamide-based chemotherapy regimen (Regimen M or Regimen I only)

Reauthorization criteria

• If the request is for Nyvepria, Udenyca, Ziextenzo, Fylnetra, Stimufend, Rolvedon, Ryzneuta, or pegfilgrastim-fpgk, the patient had an inadequate response, or has a contraindication or intolerance to Neulasta or Fulphila; AND
• Patient continues to meet indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc.; AND
• Absence of unacceptable toxicity (examples: splenic rupture, ARDS, serious allergic reactions/anaphylaxis, sickle cell crisis, glomerulonephritis, leukocytosis, thrombocytopenia, capillary leak syndrome, tumor growth stimulation, aortitis, myelodysplastic syndrome, acute myeloid leukemia in breast/lung cancer patients, etc.)
• Coverage for BMT failure or engraftment delay, PBPC mobilization and transplant, and Acute radiation exposure may not be renewed

Approval duration

4 months (renewable); 1 dose only, not renewable (BMT failure, PBPC mobilization); 2 doses only, not renewable (H-ARS)