ModifiedUnitedHealthcarePolicy CSOH2025D0061.D

White Blood Cell Colony Stimulating Factors Oh Cs

UnitedHealthcare Medical Benefit Drug Policy for white blood cell colony stimulating factor (CSF) products applicable only to Ohio members; covers list of long-acting and short-acting CSF agents for non-oncology conditions and references Ohio Department of Medicaid criteria and separate oncology policy for oncology indications.

Policy Summary

PayerUnitedHealthcare

PolicyWhite Blood Cell Colony Stimulating Factors Oh Cs

Policy CodePolicy CSOH2025D0061.D

Change TypeRevised CSF list; added product and HCPCS code

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must document and justify medical necessity for non-oncology CSF use per Ohio Medicaid Unified Preferred Drug List Criteria and Ohio Administrative Code 5160-1-01.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable white blood cell colony stimulating factors (CSFs) for non-oncology conditions; added Ryzneuta (efbemalenograstim alfa-vuxw).

17Listed CSF products (including 'any FDA-approved')

1New HCPCS code added (J9361)

Coverage Summary

This policy applies only to Ohio and covers white blood cell colony stimulating factor (CSF) products for non-oncology conditions, including the listed long-acting and short-acting CSF agents; it references the Ohio Department of Medicaid Unified Preferred Drug List Criteria for medical necessity and directs oncology indications to a separate Oncology Medication Clinical Coverage policy (do not duplicate oncology criteria).

General Medical Necessity for CSFs (non-oncology conditions)

White blood cell colony stimulating factors (CSFs) are considered medically necessary in certain circumstances. For medical necessity clinical coverage criteria for non-oncology conditions, refer to the Ohio Department of Medicaid Unified Preferred Drug List Criteria.

Requested product: Request is for a white blood cell colony stimulating factor product listed in this policy or any FDA-approved CSF not listed
Indication is a non-oncology condition
For oncology indications, see the separate Oncology Medication Clinical Coverage (for Ohio Only) policy
State criteria: Medical necessity will be evaluated using Ohio Administrative Code 5160-1-01 and Ohio Department of Medicaid Unified Preferred Drug List Criteria
Refer to state criteria for specific clinical requirement details

Applicable Codes

Applicable HCPCS/J-codes and Q-codes (listed for reference)mixed

J1442	Injection, filgrastim, (G-CSF), excludes biosimilars, 1 microgram
J1447	Injection, tbo-filgrastim, 1 microgram
J1449	Injection, eflapegrastim-xnst, 0.1 mg
J2506	Injection, pegfilgrastim, 0.5 mg
J2820	Injection, sargramostim (GM-CSF), 50 mcg
J9361	Injection, efbemalenograstim alfa-vuxw, 0.5 mg
Q5101	Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 microgram
Q5108	Injection, pegfilgrastim-jmdb (Fulphila), biosimilar, 0.5 mg
Q5110	Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 microgram
Q5111	Injection, pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mg

1–10 of 16

1/2

Billing Rule

Code usage for CSF products

Bill using the applicable HCPCS/J or Q-codes listed in this policy corresponding to the specific CSF product administered.

J1442
J1447
J1449
J2506
J2820
J9361
Q5101
Q5108
Q5110
Q5111
Q5120
Q5122
Q5125
Q5127
Q5130
Q5148

Provider Actions

Documentation Required

Follow Ohio Medicaid clinical criteria

Providers must document and justify medical necessity for non-oncology CSF use in accordance with the Ohio Department of Medicaid Unified Preferred Drug List Criteria and Ohio Administrative Code 5160-1-01.

Prior Authorization

Prior authorization / medical necessity evaluation

Requests for CSFs that are stated as unproven or subject to a coverage or quantity limit will be evaluated for medical necessity per Ohio Administrative Code 5160-1-01; prior authorization may be required per state rules and the payer's processes.

Prior authorization may be required and will be evaluated per OAC 5160-1-01 and payer processes.

Background

This Ohio-only policy provides coverage guidance for white blood cell colony stimulating factor agents used for non-oncology conditions; oncology uses are addressed by a separate Oncology Medication Clinical Coverage policy aligned with the NCCN Drugs & Biologics Compendium.

CSF: White blood cell colony stimulating factors, including G-CSF and GM-CSF agents (e.g., filgrastim, pegfilgrastim, sargramostim).