CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Use of filgrastim (Neupogen) and filgrastim biosimilars — prophylaxis for chemotherapy-induced febrile neutropenia

Appendices listing chemotherapy regimens with intermediate risk of febrile neutropenia and patient risk factors relevant to use of filgrastim and its biosimilars; intended for clinicians and reviewers managing prophylaxis for chemotherapy-induced neutropenia.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUse of filgrastim (Neupogen) and filgrastim biosimilars — prophylaxis for chemotherapy-induced febrile neutropenia

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen requesting prior authorization, document the chemotherapy regimen (check Appendix B for intermediate 10–19% FN risk) and indicate patient-specific risk factors from Appendix C.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13+chemotherapy categories in Appendix B

10-19%incidence range for FN

9patient risk factors listed

Coverage Criteria — Filgrastim Prophylaxis

Chemotherapy Regimens with Intermediate FN Risk (Appendix B)

Regimen
Docetaxel ± trastuzumab
AC (doxorubicin, cyclophosphamide) + sequential docetaxel (taxane portion only)
AC + sequential docetaxel + trastuzumab
Paclitaxel every 21 days ± trastuzumab
TC (docetaxel, cyclophosphamide)
Cisplatin/paclitaxel
Carboplatin/paclitaxel
CHOP ± rituximab (including pegylated liposomal doxorubicin variants)
GDP ± rituximab (gemcitabine, dexamethasone, cisplatin/carboplatin; with or without rituximab)
FOLFIRINOX (fluorouracil, leucovorin, oxaliplatin, irinotecan)
Irinotecan-containing regimens (e.g., irinotecan; irinotecan/cisplatin)
Carboplatin/docetaxel
Cabazitaxel
Etoposide/carboplatin
BEP (bleomycin, etoposide, cisplatin)

Regimen
FOLFIRINOX (pancreatic) (fluorouracil, leucovorin, oxaliplatin, irinotecan)
Cabazitaxel (prostate)
Etoposide/carboplatin (small cell lung cancer)
BEP (bleomycin, etoposide, cisplatin) (testicular)
Etoposide/cisplatin (testicular)
Docetaxel (uterine sarcoma)

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization: regimen and patient risk assessment

Prior authorization: When requesting prophylactic granulocyte colony-stimulating factor (G-CSF) for chemotherapy-associated febrile neutropenia (FN) prevention, document the patient’s chemotherapy regimen and an assessment of the regimen-specific FN risk. Regimens listed in Appendix B (Selected Chemotherapy Regimens with an Incidence of Febrile Neutropenia of 10% to 19%) should be identified when present; if the patient’s regimen is not listed in Appendix B but is believed by the provider to carry intermediate FN risk, include a clear rationale linking the regimen to an estimated 10–19% FN risk.

Identify and record the chemotherapy regimen (use Appendix B as applicable).
State whether the regimen is listed in Appendix B or provide clinical justification if not listed.
If regimen falls in 10–19% FN risk range, document why G-CSF prophylaxis is being requested.

Documentation Required

Documentation: presence of patient-specific risk factors

Documentation of patient-specific risk factors: when submitting a prior authorization request, document presence or absence of relevant individual risk factors that increase FN risk. At minimum, record whether any of the following apply:

Active infection, open wound, or recent surgery
Age ≥ 65 years
Bone marrow involvement by tumor causing cytopenias
Previous chemotherapy or radiation therapy
Poor nutritional status
Poor performance status
Previous episodes of febrile neutropenia
Other serious comorbidities (e.g., renal or liver dysfunction, HIV, cardiovascular disease)
Persistent neutropenia

Step Therapy

Step-therapy: not specified in these sections

Step-therapy requirements: Not specified in these sections. If any plan-level step-therapy rules apply, they are documented elsewhere; absence of step-therapy language here does not imply coverage without meeting other prior authorization or clinical criteria.

No step-therapy requirements are specified within Appendix B or C.
Providers should verify the member’s benefit plan or other policy sections for any step edits.

Note

Provider note: intermediate-risk regimens and use of prophylactic G-CSF

Use of filgrastim (or other G-CSF) for prophylaxis may be considered when a chemotherapy regimen confers intermediate FN risk (10–19%); absence from Appendix B does not preclude use. When the regimen is not listed, include clinical rationale linking regimen characteristics or patient factors to an intermediate FN risk to support the request.

If regimen listed in Appendix B, note the specific regimen name from the appendix.
If regimen not listed, document the clinical rationale for estimating 10–19% FN risk (literature citation, regimen components, or expert opinion) and relevant patient risk factors.

Risk Classification and Key Terms

Intermediate-risk chemotherapy and patient risk factors for febrile neutropenia

Febrile neutropenia risk categoryRegimens listed in Appendix B are classified as intermediate risk with an incidence of febrile neutropenia of 10–19%.

Age-related riskAge greater than or equal to 65 years is a listed patient-specific risk factor that increases FN risk.

Active infection or recent surgeryActive infections, open wounds, or recent surgery are patient risk factors that raise FN risk.

Prior therapy and prior FNPrevious chemotherapy or radiation therapy and previous episodes of febrile neutropenia increase individual FN risk.

Bone marrow involvement and persistent neutropeniaBone marrow involvement by tumor producing cytopenias and persistent neutropenia are listed as risk factors.

Comorbidities and functional statusOther serious comorbidities (renal/liver dysfunction, HIV, cardiovascular disease), poor nutritional status, and poor performance status are included as risk modifiers.

Background — Scope of Appendices

Appendix B identifies chemotherapy regimens that have an estimated incidence of febrile neutropenia of 10% to 19%. These intermediate-risk regimens (examples include taxane-containing schedules such as docetaxel ± trastuzumab, AC followed by docetaxel, paclitaxel q21 days ± trastuzumab, platinum/taxane combinations, CHOP ± rituximab, GDP ± rituximab, and multi‑agent regimens such as FOLFIRINOX) signal clinical scenarios in which primary prophylaxis with granulocyte colony‑stimulating factors may be considered depending on individual patient risk factors. Appendix B is illustrative: the listed regimens show contexts where the baseline regimen risk falls within the 10–19% range and therefore may prompt closer assessment for prophylactic filgrastim use.