CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Medical Injectable Granulocyte Colony-Stimulating Factors (G-CSF) — Coverage Criteria

Form and criteria for prior authorization of outpatient medical benefit injectable G-CSF products for members (prevention of chemotherapy-induced febrile neutropenia and related uses). Affects providers requesting coverage for listed G-CSF agents.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Medical Injectable G-CSF — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the outpatient medical injectable G-CSF request form by fax to 833-619-5745 with clinical justification and supporting attachments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥1listed non-preferred G-CSF products

833-619-5745fax number to submit request form

J2506, Q5111, Q5108, Q5120sample HCPCS-like codes

Coverage Criteria for Outpatient G-CSF

Coverage criteria for outpatient G-CSF

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Medical Injectable G-CSF — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the outpatient medical injectable G-CSF request form by fax to 833-619-5745 with clinical justification and supporting attachments.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Indication: Medication is being used to prevent chemo-induced febrile neutropenia (or other intended use is documented)

If not for prevention of chemo-induced febrile neutropenia, provider must state intended use on the request form

Clinical documentation: Submit cancer diagnosis and staging, the complete chemotherapy regimen, and risk stratification for febrile neutropenia (low/intermediate/high)

Attach all pertinent clinical information (use outpatient medical injectable G-CSF request form and fax to 833-619-5745)

Risk factors: Member has one or more risk factors such as persistent neutropenia (ANC ≤ 1500/mm3), history of febrile neutropenia, prior exposure to chemotherapy or radiation, bone marrow involvement by tumor, recent surgery/open wounds, liver or renal dysfunction, age >65 receiving full chemo dose intensity, or comorbidities that increase risk of serious infection≤ 1500/mm3

Document which risk factors are present

Coding and Clinical Values

Listed G-CSF products (non-preferred list context)HCPCS

Q5111	Udenyca
J2506	Neulasta
Q5108	Fulphila
Q5120	Ziextenzo

Other listed non-preferred products (descriptions without HCPCS in source)mixed

Stimufend	Stimufend
Fylnetra	Fylnetra
Rolvedon	Rolvedon

Absolute neutrophil count (ANC) — clinical threshold value

ANC thresholdAbsolute neutrophil count (ANC) ≤ 1500/mm3

Source contextANC threshold is listed as ‘Persistent neutropenia (ANC of 1500/mm3 or less)’ in the form

Clinical relevancePersistent neutropenia (ANC ≤1500/mm3) is a documented risk factor considered when assessing need for prophylactic G-CSF

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Submit the Outpatient Medical Injectable Granulocyte Colony-Stimulating Factors Request Form with clinical justification and all supporting attachments. Fax the completed form to 833-619-5745 (medical benefit only). Include member demographics, benefit type (Medicare or Commercial), requesting physician and facility information, date of service, and diagnosis code(s).

Fax: 833-619-5745 (medical benefit only)
Include: member name, DOB, UMI, benefit type (Medicare or Commercial)
Include: requesting physician name, NPI, address, office contact, phone/fax
Include: facility name, facility NPI, facility address, date of service, diagnosis codes

Step Therapy

Step Therapy for Non-Preferred Products

Step therapy applies: non-preferred products will be considered only after documented failure of an adequate therapeutic trial of a preferred product, or when the preferred product is not tolerated or is contraindicated. Medicare members already established on a non-preferred therapy are not required to trial a preferred option.

Non-preferred examples: Udenyca (Q5111), Stimufend, Fylnetra, Neulasta (J2506), Rolvedon, Fulphila (Q5108), Ziextenzo (Q5120)
Non-preferred will be denied unless documentation shows prior failure/intolerance/contraindication to preferred product
Medicare members currently on non-preferred therapy are exempt from step therapy

Documentation Required

Required Submission Information

Required submission information and documentation — verify member eligibility and benefits, and attach all pertinent clinical information. On the form, answer cancer diagnosis and staging, intended use (e.g., prevention of chemo-induced febrile neutropenia), complete chemotherapy regimen, FN risk level (low/intermediate/high), and any risk factors (bone marrow involvement, recent surgery/open wounds, liver/renal dysfunction, age >65 on full chemo dose intensity, relevant comorbidities). Indicate whether attachments are included.

Verify eligibility and benefits with the health plan before submission
Document cancer diagnosis and staging
State whether medication is for prevention of chemo-induced febrile neutropenia; if no, state intended use
Provide complete chemotherapy regimen
Assess and document FN risk level: Low / Intermediate / High
List specific FN risk factors and comorbidities; attach supporting clinical records
Indicate whether attachments are included (YES/NO)

Denial Risk

Denial Risk for Non-Preferred Product Usage

Denial Risk — Use of a non-preferred product without documentation of prior failure, intolerance, or contraindication to a preferred product may result in denial. Ensure clinical justification explicitly addresses why a preferred agent is inappropriate when requesting a non-preferred product.

Requests for non-preferred agents require documentation of prior preferred product failure, intolerance, or contraindication
Medicare members already on non-preferred therapy are exempt from this requirement

Initial Therapy — Consideration Rules

Consideration of non-preferred G-CSF

Step requirement: A non-preferred G-CSF will be considered only after documented therapy failure after an adequate trial of a preferred product, or when the preferred product is not tolerated or is contraindicated

Medicare members currently established on a non-preferred therapy are exempt from the trial requirement; provide documentation of failure, intolerance, or contraindication on the request form

Step	Requirement	Notes
1	Try a preferred G-CSF agent first prior to use of a non-preferred product; a non-preferred product will be considered only after documented failure of an adequate therapeutic trial of a preferred product, or if the preferred product is not tolerated or is contraindicated.	Medicare members currently established on a non-preferred therapy are exempt from the step requirement and are not required to try a preferred option.

Definitions and Risk Factors

Risk factors for febrile neutropenia — categories and contributing factors

Risk categoriesLow, Intermediate, High (risk of febrile neutropenia)

Key hematologic risk factorPersistent neutropenia: ANC of 1500/mm3 or less

Patient history factorsHistory of febrile neutropenia; prior exposure to chemotherapy or radiation

Clinical and surgical contributorsBone marrow involvement by tumor; recent surgery and/or open wounds

Physiologic and comorbidity factorsLiver or renal dysfunction; age >65 receiving full chemotherapy dose intensity; comorbidities that increase risk of serious infection

Background

Granulocyte colony-stimulating factors (G-CSFs) are indicated to prevent chemotherapy-induced febrile neutropenia by stimulating neutrophil production. Clinical decision-making should consider the patient’s cancer diagnosis and staging, the complete chemotherapy regimen, and individualized risk factors—such as persistent neutropenia (ANC ≤ 1500/mm3), prior febrile neutropenia, bone marrow involvement, recent surgery or open wounds, liver or renal dysfunction, age >65 receiving full chemotherapy intensity, and relevant comorbidities—when assessing the need for prophylactic G-CSF.

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