Nyvepria — Point32Health

Preferred products

• Neulasta
• Fulphila

Initial criteria

• For hematopoietic subsyndrome of acute radiation syndrome: Documentation the requested use is for hematopoietic subsyndrome of acute radiation syndrome AND documented previous failure, contraindication, or clinical inappropriateness with Neulasta and Fulphila.
• For prophylaxis of chemotherapy-induced neutropenia: Documented diagnosis of solid tumor or non-myeloid malignancy in a patient receiving myelosuppressive chemotherapy AND documentation of one (1) of the following: (a) The patient will be receiving a chemotherapy regimen associated with a high risk (>20%) of febrile neutropenia based on National Comprehensive Cancer Network clinical guidelines for myeloid growth factors OR (b) The patient will be receiving a chemotherapy regimen associated with an intermediate risk (10 to 20%) of febrile neutropenia based on National Comprehensive Cancer Network clinical guidelines for myeloid growth factors AND the patient has at least one of the following risk factors: age ≥65 years; active infections, open wounds, or recent surgery; advanced disease (stage 2 or higher or bone marrow involvement); prior chemotherapy or radiation therapy; pre-existing neutropenia; poor performance status (ECOG score of 2 to 5) or poor nutritional status; comorbidities (cardiovascular disease, renal dysfunction with creatinine clearance <50, liver dysfunction with bilirubin >2.0, or HIV infection); concern with member’s comprehension of the severity of fever development or access to a hospital if fever developed; chronic immunosuppression in the post-transplant setting; OR (c) The patient is receiving dose-dense myelosuppressive chemotherapy; OR (d) The patient has experienced a neutropenic complication (e.g., febrile neutropenia, dose-limiting neutropenic event) from a prior cycle of the same chemotherapy. AND documented previous failure, contraindication, or clinical inappropriateness with Neulasta and Fulphila.

Approval duration

6 months