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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsViva Health Plan Cosela Prior Auth | OpenPayer
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    CurrentViva Health PlanPolicy IC-0592

    Cosela (trilaciclib) Intravenous Therapy

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    This policy governs prior authorization and medical necessity for intravenous Cosela (trilaciclib) used to reduce chemotherapy-induced myelosuppression in adults with extensive-stage small cell lung cancer under the Viva Health Plan pharmacy benefit.

    Policy Summary
    PayerViva Health Plan
    PolicyCosela (trilaciclib) Intravenous Therapy
    Policy CodePolicy IC-0592
    Change TypeNo material change
    Effective DateN/A
    Last ReviewAug 4, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests; initial approval is valid for 4 months and renewal may be requested every 4 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4 monthsInitial authorization
    4 monthsRenewal interval
    3,000 mg/21 daysMaximum dose
    240 mg/m²Recommended dose
    Adults with ES-SCLC

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Covered population

    Coverage Criteria

    Initial Therapy

    Covered when all universal and indication-specific criteria are met.

    Initial approval

    • Universal criteria

      • Member is at least 18 years of age.
      • Cosela will not be used concomitantly with colony-stimulating factors for primary prophylaxis of febrile neutropenia prior to day 1 of cycle 1 of chemotherapy.

    • Disease and treatment criteria

      • Member has extensive-stage small cell lung cancer.
      • Cosela is used as prophylactic therapy to decrease the incidence of chemotherapy-induced myelosuppression.

    • Qualifying chemotherapy regimen

      • Platinum and etoposide regimen: Platinum (carboplatin or cisplatin) and etoposide-containing regimen.
      • Topotecan regimen: Topotecan-containing regimen.

    Continuation Therapy

    Renewal may be approved when all renewal criteria are met.

    Renewal criteria

    • Continued eligibility: Member continues to meet universal and other relevant indication-specific criteria identified in the initial approval section, including applicable concomitant therapy requirements, performance status, and other criteria identified in section III.

      Prerequisite therapy is excluded from this reference.

    • Safety: Member has no unacceptable toxicity from Cosela.

      Examples include severe injection-site reactions including phlebitis and thrombophlebitis, acute drug hypersensitivity reactions including facial edema and urticaria, and interstitial lung disease or pneumonitis.

    • Continued qualifying chemotherapy regimen

      • Platinum and etoposide regimen: Platinum (carboplatin or cisplatin) and etoposide-containing regimen.

    Coverage requires that Cosela not be used concomitantly with colony-stimulating factors for primary prophylaxis of febrile neutropenia before day 1 of cycle 1 of chemotherapy.

    Renewal is not supported when the member has unacceptable toxicity from Cosela, including severe injection-site reactions such as phlebitis or thrombophlebitis, acute drug hypersensitivity reactions such as facial edema or urticaria, or interstitial lung disease or pneumonitis.

    Initial Approval Criteria

    Initial Approval Criteria

    Initial authorization is provided when all universal and indication-specific criteria are met.

    Initial approval

    • Universal criteria

      • Member is at least 18 years of age.
      • Cosela will not be used concomitantly with colony-stimulating factors for primary prophylaxis of febrile neutropenia prior to day 1 of cycle 1 of chemotherapy.

    • Disease and treatment criteria

      • Member has extensive-stage small cell lung cancer.

    Renewal Criteria

    Renewal Criteria

    Renewal may be approved when all continuation criteria are met.

    Continuation criteria

    • Continued eligibility: Member continues to meet universal and other relevant indication-specific criteria identified in the initial approval section, including applicable concomitant therapy requirements, performance status, and other criteria identified in section III.

      Prerequisite therapy is excluded from this reference.

    • Safety: Member has no unacceptable toxicity from Cosela.

      Examples include severe injection-site reactions including phlebitis and thrombophlebitis, acute drug hypersensitivity reactions including facial edema and urticaria, and interstitial lung disease or pneumonitis.

    • Continued qualifying chemotherapy regimen

    Coding and Dosing Information

    Covered HCPCS CodesHCPCSCovered
    J1448Injection, trilaciclib, 1 mg
    Covered NDCsNDCCovered
    73594-0101-xxCosela 300 mg single-dose vial
    Covered Diagnosis CodesICD-10Covered
    D61.810Antineoplastic chemotherapy induced pancytopenia
    D70.1Agranulocytosis secondary to cancer chemotherapy
    D70.9Neutropenia, unspecified
    T45.1X5AAdverse effect of antineoplastic and immunosuppressive drugs, initial encounter
    T45.1X5DAdverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter
    T45.1X5SAdverse effect of antineoplastic and immunosuppressive drugs, sequela
    Z51.11Encounter for antineoplastic chemotherapy
    Z51.12Encounter for antineoplastic immunotherapy
    Maximum Dose
    Maximum dose3,000 billable units
    Equivalent amount3,000 mg
    Dosing intervalEvery 21 days
    Recommended Dose
    Recommended dose240 mg/m² per dose
    Dose basis240 mg/m²
    Administration frequencyPer dose

    Authorization and Denial Considerations

    Prior Authorization

    Obtain authorization every 4 months

    Prior authorization is required. Initial authorization is valid for 4 months (120 days), and renewal may be requested every 4 months (120 days).

    Denial Risk

    Confirm initial eligibility

    Authorization may be denied if the member is younger than 18 years, Cosela is not being used prophylactically to decrease chemotherapy-induced myelosuppression, the member does not have extensive-stage small cell lung cancer, or the chemotherapy regimen is not platinum with etoposide or topotecan.

    Denial Risk

    Avoid prohibited concomitant prophylaxis

    Therapy Background

    Cosela (trilaciclib) is an intravenous CDK4/6 inhibitor administered before chemotherapy to reduce the incidence of chemotherapy-induced myelosuppression. Coverage applies to prophylactic use in adults with extensive-stage small cell lung cancer receiving specified myelosuppressive chemotherapy regimens, including platinum plus etoposide or topotecan.

    Quantity Limit

    Quantity Limit
    DrugCosela (trilaciclib)
    Maximum quantity3,000 billable units
    Equivalent amount3,000 mg

    Administration Site and Timing

    Note

    Administer in the infusion center

    Administer Cosela as a 30-minute intravenous infusion completed within 4 hours before the start of chemotherapy on each day chemotherapy is administered.

    Policy Summary
    PayerViva Health Plan
    PolicyCosela (trilaciclib) Intravenous Therapy
    Policy CodePolicy IC-0592
    Change TypeNo material change
    Effective DateN/A
    Last ReviewAug 4, 2026
    Next Review DateN/A
    Key ActionSubmit prior authorization requests; initial approval is valid for 4 months and renewal may be requested every 4 months.
    SourceLink
    On This Page
    Coverage CriteriaInitial Approval CriteriaRenewal CriteriaCoding and Dosing InformationAuthorization and Denial ConsiderationsTherapy BackgroundQuantity LimitAdministration Site and Timing
  1. Topotecan regimen: Topotecan-containing regimen.
    2. Cosela is used as prophylactic therapy to decrease the incidence of chemotherapy-induced myelosuppression.

  2. Qualifying chemotherapy regimen

    • Platinum and etoposide regimen: Platinum (carboplatin or cisplatin) and etoposide-containing regimen.
    • Topotecan regimen: Topotecan-containing regimen.
    3. Platinum and etoposide regimen: Platinum (carboplatin or cisplatin) and etoposide-containing regimen.
  3. Topotecan regimen: Topotecan-containing regimen.
    4. Infusion Administration
    Infusion duration30 minutes
    RouteIntravenous infusion
    TimingCompleted within 4 hours prior to the start of chemotherapy on each day chemotherapy is administered
    Sequential Dose Interval
    Sequential dose intervalNot greater than 28 hours
    ApplicationInterval between doses of Cosela on sequential days
    Maximum interval28 hours

    Authorization may be denied when Cosela is used concomitantly with colony-stimulating factors for primary prophylaxis of febrile neutropenia before day 1 of cycle 1 of chemotherapy.

    Denial Risk

    Assess toxicity before renewal

    Renewal may be denied when the member experiences unacceptable toxicity, including severe injection-site reactions, phlebitis or thrombophlebitis, acute drug hypersensitivity reactions such as facial edema or urticaria, or interstitial lung disease or pneumonitis.

    Billing Rule

    Do not exceed the dose limit

    Dosing above 3,000 billable units (3,000 mg) every 21 days exceeds the policy limit.