Colony Stimulating Factors - Rolvedon
Defines medical-benefit coverage, prior authorization, clinical criteria, dosing limits, and exclusions for Rolvedon (eflapegrastim-xnst) subcutaneous injection under Cigna health benefit plans.
Added Hematopoietic Acute Radiation Syndrome (H-ARS) as a new condition of approval with a new dosing limitation.
Updated policy title and revised coverage statement wording for chemotherapy indication to 'Cancer in a Patient Receiving Myelosuppressive Chemotherapy.'
Prior Authorization remains required; dosing limits and prescriber specialty requirements reiterated.
Included examples of risk factors for febrile neutropenia in policy notes.