CurrentHighmark Blueshield NenyPolicy N/A

Outpatient injectable granulocyte colony-stimulating factors (G-CSFs) request form

This document is a request/authorization form used by providers to request outpatient medical benefit coverage for injectable G-CSF products for cancer patients (e.g., to prevent chemotherapy-induced febrile neutropenia). It applies to Highmark Blue Shield NENY members and their providers completing prior authorization information.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient injectable granulocyte colony-stimulating factors (G-CSFs) request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with diagnosis, chemo regimen, risk assessment and attach pertinent clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

listNon-preferred G-CSF products enumerated on the form

3Risk-assessment questions

YES/NOFields for attachment of supporting clinical information

1Fax number for submission

Coverage Criteria

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient injectable granulocyte colony-stimulating factors (G-CSFs) request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with diagnosis, chemo regimen, risk assessment and attach pertinent clinical documentation.

SourceLink

On This Page

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Coverage Criteria

Non-preferred product will be considered when ALL of the following apply:

ALL of the following

Member has documented therapy failure after an adequate therapeutic trial of a preferred product, or the preferred product has not been tolerated or is contraindicated.
If member is a Medicare beneficiary currently established on a non-preferred therapy, a trial of a preferred product is not required (medical continuity for established Medicare members).
Authorization request includes completed clinical risk assessment documenting risk category, risk factors, and intended use (e.g., prevention of chemotherapy‑induced febrile neutropenia).
Authorization requires completion of clinical risk assessment (risk category, risk factors, intended use).
Request includes supporting documentation: cancer diagnosis and stage, complete chemotherapy regimen, and relevant labs/clinical notes (e.g., ANC values).
Please attach all pertinent clinical information (lab values, prior therapy records).
Request documents patient risk level for febrile neutropenia (low, intermediate, or high) and any specific increased risk factors (examples below).
At least one of the following increased risk factors must be present:
- Persistent neutropenia (ANC ≤ 1500/mm3).
- History of febrile neutropenia.
- Prior exposure to chemotherapy or radiation.
- Bone marrow involvement by tumor.
- Recent surgery and/or open wounds.
- Liver or renal dysfunction.
- Age > 65 years receiving full chemotherapy dose intensity.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all listed outpatient medical injectable G-CSFs. Include the patient's identifiers, diagnosis code(s), chemotherapy regimen, intended use (e.g., prevention of chemotherapy-induced febrile neutropenia), and supporting clinical documentation when submitting the request form.

Affected products: Neulasta (J2506), Fulphila (Q5108), Ziextenzo (Q5120), Udenyca (Q5111), Stimufend, Nyvepria (Q5120), Fylnetra, Rolvedon
Fax completed form and attachments to 833-619-5745 (Medical Benefit Only)
Required form fields: Member name, DOB, UMI, payer type (Medicare/Commercial), requesting physician name and NPI, facility and facility NPI, date of service, diagnosis code(s)

Step Therapy

Non-Preferred Product Consideration

Non-preferred products will only be considered after documentation of therapeutic failure of a preferred product, or if a preferred product is not tolerated or is contraindicated. For Medicare members already established on a non-preferred therapy, a trial of a preferred product is not required.

Non-preferred examples: Neulasta (J2506), Fulphila (Q5108), Ziextenzo (Q5120), Udenyca (Q5111), Stimufend, Nyvepria (Q5120), Fylnetra, Rolvedon
When requesting a non-preferred product, include documentation of prior preferred product trial and reason for failure or intolerance

Documentation Required

Required Form Fields and Attachments

Complete and attach the outpatient G-CSF request form and all pertinent clinical information to support medical necessity. Required fields and attachments include member identifiers, physician/facility information, diagnosis code(s), intended use, complete chemotherapy regimen, risk level for febrile neutropenia, and any relevant labs or prior treatment documentation.

Attach pertinent clinical records demonstrating trial and failure of preferred agents when applicable
Indicate whether use is for prevention of chemo-induced febrile neutropenia and provide staging/diagnosis details
Document ANC values, comorbidities, recent surgery, organ dysfunction, age >65 status, prior chemo/radiation, bone marrow involvement, and other risk factors

Denial Risk

Documentation and Denial Risk

Failure to document prior trial and failure of a preferred product when requesting a non-preferred product may result in non-coverage or denial. To avoid delays or denials, include complete supporting documentation with the prior authorization submission.

Missing documentation of prior therapy trial or reason for failure/intolerance increases denial risk
Verify member eligibility and benefits through the health plan prior to submission

Background

Granulocyte colony-stimulating factors (G-CSFs) reduce the incidence of chemotherapy-induced febrile neutropenia; this form is an authorization request used to obtain outpatient medical-benefit coverage for injectable G-CSFs. Providers must complete the form with member identifiers, cancer diagnosis and staging, whether the agent is intended to prevent chemo-induced febrile neutropenia, the full chemotherapy regimen, febrile neutropenia risk category (Low/Intermediate/High), and any increased-risk factors (for example, ANC ≤1500/mm3, history of FN, prior chemo/radiation, bone marrow involvement, recent surgery/open wounds, liver or renal dysfunction, age >65 on full-dose chemotherapy, or comorbidities that raise infection risk). The form requests that pertinent clinical information be attached to support the authorization.

Step	Requirement	Notes
1	Try a preferred granulocyte colony-stimulating factor (G-CSF) agent first	Non-preferred products will be considered only after documented therapy failure of an adequate trial of a preferred product, or if the preferred product is not tolerated or is contraindicated; Medicare members already established on a non-preferred therapy are exempt from the preferred-agent requirement

Biosimilar / Non-preferred Products

Billing Rule

Neulasta (J2506) listed as non‑preferred

Neulasta (J2506) is listed on the form as a non‑preferred product; requests for Neulasta will be handled under the non‑preferred product consideration rules (documented failure of preferred product or intolerance/contraindication).

Neulasta is shown with HCPCS code J2506 on the non‑preferred list.

Billing Rule

Neulasta non‑preferred — follow non‑preferred consideration rules

Neulasta is included among non‑preferred options; approval for a non‑preferred biosimilar or reference product requires documentation that a preferred product failed, was not tolerated, or is contraindicated.

Medicare members already established on a non‑preferred therapy are exempt from trying a preferred product.

Billing Rule

Neulasta requests must document preferred‑product failure/intolerance

Neulasta appears on the non‑preferred product list alongside other agents; when requesting Neulasta the provider must document prior preferred‑product trial failure or intolerance/contraindication per the form instructions.

List on form shows Neulasta with associated HCPCS code; include supporting documentation of trial/failure or reason for exception.

OpenPayer

Outpatient injectable granulocyte colony-stimulating factors (G-CSFs) request form

Coverage Criteria

Codes and Products

Provider Actions and Requirements

Background

Definitions

Step Therapy Rules

Site of Care

Biosimilar / Non-preferred Products

J2506	Neulasta
Q5108	Fulphila
Q5120	Ziextenzo / Nyvepria
Q5111	Udenyca