CurrentMass General Brigham Health PlanPolicy N/A

Short Acting Colony Stimulating Factors (CSFs)

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Defines pharmacy benefit coverage, prior authorization requirements, and clinical criteria for short-acting CSF products for Mass General Brigham Health Plan members under the pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyShort Acting Colony Stimulating Factors (CSFs)

Policy CodePolicy N/A

Change TypeRevised — shifts to pharmacy benefitupdates reauthorization and preferred agent rules

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionSubmit prior authorization via the pharmacy benefit; if member is new to the plan (≤90 days), include medical records showing current treatment with the requested drug.

SourceLink

POLICY UPDATE CHANGES

Policy updated to indicate it no longer applies to the medical benefit and applies to the pharmacy benefit with prior authorization requirements.

Reauthorization criteria now require trial and failure with Zarxio (preferred agent) or documentation of clinical rationale why Zarxio is inappropriate.

Added and removed specific agents over time; most recent removal: Nypozi removed as it moved to nonformulary status.

6 monthsapproval length

Prior authorization

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CurrentMass General Brigham Health PlanPolicy N/A

Short Acting Colony Stimulating Factors (CSFs)

Customize your policy alerts

Sign up for all Mass General Brigham Health Plan policy alerts

Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines pharmacy benefit coverage, prior authorization requirements, and clinical criteria for short-acting CSF products for Mass General Brigham Health Plan members under the pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyShort Acting Colony Stimulating Factors (CSFs)

Policy CodePolicy N/A

Change TypeRevised — shifts to pharmacy benefitupdates reauthorization and preferred agent rules

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionSubmit prior authorization via the pharmacy benefit; if member is new to the plan (≤90 days), include medical records showing current treatment with the requested drug.

SourceLink

POLICY UPDATE CHANGES

Policy updated to indicate it no longer applies to the medical benefit and applies to the pharmacy benefit with prior authorization requirements.

Reauthorization criteria now require trial and failure with Zarxio (preferred agent) or documentation of clinical rationale why Zarxio is inappropriate.

Added and removed specific agents over time; most recent removal: Nypozi removed as it moved to nonformulary status.

6 monthsapproval length

Prior authorization

Coverage Criteria

Authorization may be granted when the member meets the applicable indication-specific and product-specific criteria below.

Covered indications — member has one of the FDA-approved or compendial indications listed in policy (examples include: AML following induction/consolidation chemotherapy; peripheral blood progenitor cell (PBPC) mobilization; myelosuppressive chemotherapy for non-myeloid malignancies; bone marrow transplantation settings; severe chronic neutropenia; hematopoietic syndrome of acute radiation syndrome; post-transplant myeloid reconstitution (Leukine); and compendial uses such as febrile neutropenia, MDS-related anemia/neutropenia, ALL post-chemotherapy, stem cell transplant indications, agranulocytosis, aplastic anemia, HIV-related neutropenia).

Preferred agent — Zarxio may be authorized for members being treated for any of the FDA indications or compendial uses when clinical criteria are met.

ALL of the following

a. Documentation of previous treatment failure, intolerance, or contraindication to Zarxio
b. Documentation of clinical rationale why Zarxio is not an appropriate therapy for the member

Dose limitation for specific agents — requested doses for Granix and Neupogen must be less than 180 mcg.

New member documentation — if the member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting current treatment with the requested drug.

Approval length — initial approvals and reauthorizations are granted for 6 months.

Drug Coding and Limits

drug codingmixed

NDCs, HCPCS, or CPT codes not specified in document

Granix/Neupogen dose limit — requested doses less than 180 mcg

Dose limitRequested doses for Granix and Neupogen must be less than 180 mcg

Applies toGranix (tbo-filgrastim) and Neupogen (filgrastim)

ContextRequirement is part of product-specific authorization criteria when requesting non-preferred agents

Provider Actions and Operational Requirements

Prior Authorization

Prior authorization required; new-member medical records

Prior authorization is required through the pharmacy benefit. If the member is new to the plan (coverage effective date ≤ 90 days), submit medical records documenting that the member is currently receiving treatment with the requested drug (excluding products obtained as samples or via manufacturer patient assistance).

Documentation Required

Must be dispensed at contracted specialty pharmacy

This medication is designated specialty and must be filled at a contracted specialty pharmacy. Use the specialty pharmacy contact information for processing (Phone: 833-895-2611; Fax: 888-656-6671).

Specialty pharmacy fill required
Specialty pharmacy phone: 833-895-2611
Specialty pharmacy fax: 888-656-6671

Definitions

Covered indications (definition list)

DefinitionIndications that are FDA-approved or compendial uses that meet approval criteria are considered covered when all approval criteria are met and the member has no exclusions to therapy

Examples (policy scope)Includes FDA and compendial indications such as AML after induction/consolidation, PBPC mobilization, myelosuppressive chemotherapy, bone marrow transplant settings, severe chronic neutropenia, hematopoietic syndrome of acute radiation syndrome, and other compendial uses

Coverage conditionCoverage requires meeting the specific clinical and product criteria outlined in the policy

Initial Authorization Criteria

Initial Authorization

Product-specific initial authorization rules.

Zarxio (preferred) — Authorization may be granted for Zarxio for members being treated for any FDA indication or compendial use when clinical criteria are met.

ALL of the following

a. Documentation of previous treatment failure, intolerance, or contraindication with Zarxio
b. Documentation of clinical rationale why Zarxio is not an appropriate therapy for the member

Dose restriction — For Granix and Neupogen, requested doses must be less than 180 mcg.

Initial approval duration — initial approvals will be granted for 6 months.

Reauthorization / Continuation Criteria

Continuation Criteria

Reauthorization requests will be approved when the following criteria are satisfied.

Documentation of prior Zarxio trial status — Submission of medical records (e.g., chart notes) documenting previous treatment failure, intolerance, or contraindication to Zarxio, or documentation of clinical rationale why Zarxio is not appropriate.

Documentation of continued benefit — Submission of medical records (e.g., chart notes) documenting continuation of therapy and a positive clinical response to therapy.

Reauthorization duration — reauthorizations will be granted for 6 months.

Step Therapy Requirements

Step	Requirement
1	Member must have trial and failure with Zarxio (documentation of previous treatment failure, intolerance, or contraindication) OR documentation of a clinical rationale why Zarxio is not an appropriate therapy for the member.

Quantity Limits

Granix, Neupogen — requested doses less than 180 mcg

Dose restrictionRequested doses for Granix and Neupogen must be less than 180 mcg

Quantity limit entryLimit applies per course as specified in the policy quantity limits

Related authorization requirementGranix and Neupogen are non-preferred agents that require documentation of prior Zarxio failure, intolerance, or clinical rationale why Zarxio is inappropriate

Site of Care Requirements

Note

Dispense through contracted specialty pharmacy

Must be dispensed at a contracted specialty pharmacy; contact the specialty pharmacy for processing and benefits coordination (Phone: 833-895-2611; Fax: 888-656-6671).

Specialty pharmacy fill required
Phone: 833-895-2611
Fax: 888-656-6671

Biosimilar Status and Preferences

Billing Rule

Zarxio designated preferred; other biosimilars may require trial/failure

Zarxio is designated the preferred filgrastim agent; other biosimilars and reference product status have been updated historically and non-preferred agents may require documentation of prior Zarxio trial and failure or clinical rationale for use.

Zarxio designated preferred agent
Other biosimilars (e.g., Nivestym, Releuko, Neupogen) may be non-preferred and require trial/failure with Zarxio or clinical rationale