CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization — Colony Stimulating Factors (Florida Medicaid PA Form)

A prior authorization form and requirements for colony stimulating factor (CSF) agents for Florida Medicaid recipients; governs PA submission, required documentation, and indications for use. Affects prescribers and pharmacies submitting PA for listed CSF products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization — Colony Stimulating Factors (Florida Medicaid PA Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed PA form with supporting medical records and recent labs via fax to 1-866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>10CSF products listed

>20%High-risk threshold

5 yearsDocumentation retention

1-866-940-7328Fax to submit form

Coverage Criteria for Colony Stimulating Factors

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization — Colony Stimulating Factors (Florida Medicaid PA Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed PA form with supporting medical records and recent labs via fax to 1-866-940-7328.

SourceLink

On This Page

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Coverage is limited to the indications listed on the PA form. The form requires the prescriber to select one of the specified diagnoses or use-cases (for example: cancer patient receiving myelosuppressive chemotherapy; bone marrow transplant; induction or consolidation chemotherapy for acute myeloid leukemia; peripheral blood progenitor cell collection and therapy; acute exposure to myelosuppressive radiation; severe neutropenia in an AIDS patient on antiretroviral therapy; or severe chronic neutropenia—congenital, cyclic, or idiopathic). Only requests that match one of these form-listed indications will be considered for approval.

Regimen / Criteria	Coverage status
Patients receiving a regimen the prescriber attests is high risk (>20%) for febrile neutropenia (provider indicates 'Yes' on PA form)	Covered when PA is approved and all required form fields and supporting documentation are submitted

Listed Agents, Codes and Clinical Parameters

Listed Colony Stimulating Factor productsNDC/Drug

Leukine	Preferred agent listed
Neupogen	Preferred agent listed
Nyvepria	Preferred agent listed
Fulphila	Non-preferred (Clinical PA required)
Fylnetra	Non-preferred (Clinical PA required)
Granix	Non-preferred (Clinical PA required)
Neulasta	Non-preferred (Clinical PA required)
Nivestym	Non-preferred (Clinical PA required)
Releuko	Non-preferred (Clinical PA required)
Rolvedon	Non-preferred (Clinical PA required)

1–10 of 14

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inv-05: High risk for febrile neutropenia — > 20% threshold as queried on form

High-risk threshold> 20% (as queried on the PA form — prescriber must attest if regimen/disease state is high risk for febrile neutropenia)

Form response optionsPrescriber selects 'Yes' or 'No' to attest high-risk status on the PA form

Use for coverage decisionAttestation of >20% risk is part of clinical risk consideration required for PA approval

inv-06: Absolute Neutrophil Count (ANC) — provider to supply cells/mm3

Absolute Neutrophil Count (ANC)Provider must supply ANC value in cells/mm3 on the PA form

Lab test dateForm requests the lab test date corresponding to the ANC value

DocumentationCopies of recent labs must be submitted for review and retained by provider for five years

inv-13: Definition — >20% risk as queried on form (high risk for febrile neutropenia)

Definition>20% risk denotes 'high risk for febrile neutropenia' as queried on the PA form; prescriber must attest whether the regimen or disease state meets this threshold

Role in criteriaThis >20% attestation is used in the clinical risk consideration node of the PA coverage criteria

Form captureThe PA form explicitly asks: 'Can the prescriber attest the disease state or prescribed regimen is high risk (> 20%) for febrile neutropenia? (Yes/No)'

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for non-preferred colony stimulating factors (CSFs). Submit the completed PA form via fax to 1-866-940-7328 with required documentation.

Fax: 1-866-940-7328
Include completed PA form and supporting documentation (see documentation callout)

Prior Authorization

Preferred vs Non-Preferred Agents

Preferred agents: Leukine®, Neupogen®, Nyvepria™. Non-preferred agents require a clinical prior authorization: Fulphila™/Fylnetra®, Granix®, Neulasta®, Nivestym®, Releuko®, Rolvedon™, Stimufend®, Udenyca®, Zarxio®, Ziextenzo™.

Preferred: Leukine®, Neupogen®, Nyvepria™
Non-Preferred (clinical PA required): Fulphila™/Fylnetra®, Granix®, Neulasta®, Nivestym®, Releuko®, Rolvedon™, Stimufend®, Udenyca®, Zarxio®, Ziextenzo™

Documentation Required

Required Supporting Documentation

Required supporting documentation must be submitted for review. Copies of medical records (diagnostic evaluations, recent chart notes) and the most recent related lab results (including ANC) are required. Providers must retain copies of all documentation for five years.

Include diagnostic evaluations and recent chart notes
Include most recent labs (Absolute Neutrophil Count)
Provider must retain documentation for 5 years

Documentation Required

Form Fields Required

The PA form must be completed in full. Required fields include recipient Medicaid ID, date of birth, recipient name, prescriber name, prescriber license, prescriber phone and fax, pharmacy name, pharmacy Medicaid provider number, pharmacy phone and fax, and drug name/strength/NDC if available. Indicate whether this is new therapy or continuation, diagnosis/indication, ANC and lab date, date range of therapy, dosing regimen, and prescriber signature/date.

Complete all form fields: recipient, prescriber, pharmacy, drug details
Specify diagnosis/indication and check applicable boxes
Provide lab test date and ANC, therapy dates, dosage/frequency
Prescriber signature and date required

Denial Risk

Incomplete Form May Be Returned

An incomplete form may be returned. Ensure all required fields and supporting documentation are included to avoid delays.

Incomplete or missing documentation may result in return of the form or denial of the request

Line of Therapy / Placement

first-line

Line of therapy indications: Use for patients receiving myelosuppressive chemotherapy; cancer patients receiving bone marrow transplant; patients receiving induction or consolidation chemotherapy for acute myeloid leukemia (AML); peripheral blood progenitor cell collection and therapy in cancer patients.

Form asks clinician to indicate whether therapy is new or a continuation.

Background on Colony Stimulating Factors

Colony stimulating factors (CSFs) are used to reduce the duration of neutropenia and the risk of febrile neutropenia in patients receiving myelosuppressive chemotherapy and in other indicated settings listed on the form (e.g., bone marrow transplant, induction/consolidation chemotherapy for AML, peripheral blood progenitor cell collection, acute radiation exposure, and severe or chronic neutropenia). The PA form specifically asks prescribers to indicate if the regimen is high risk (>20%) for febrile neutropenia to support the clinical rationale for CSF use.

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