UnitedHealthcare
Neulasta (pegfilgrastim)
Drugs for the Blood : Drugs for the Blood
  • Neutropenia:
    Duration: 12 Month(s)
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Supporting Documentation Requirements: Medical Tests
    Risk Factor for Developing Febrile Neutropenia (FN): 1 of Age greater than 65 years;Bone marrow involvement;Extensive prior chemotherapy/radiation therapy;Liver dysfunction;Open wounds;Poor renal function;Pre-existing neutropenia;Recent surgery
    Documented Diagnosis: Yes
    Criteria includes risk factor for developing FN: Yes

  • Prior Authorization: Neutropenia:
    PA Applies
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