Health Net
Ziextenzo (pegfilgrastim-bmez)
Drugs for the Blood : Drugs for the Blood
  • Prior Authorization: Neutropenia:
    PA Applies
  • Neutropenia:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
    Dosing Limit Defined In Policy: 2 of 6mg;Per chemotherapy cycle
    Billing Note(s): HCPCS Code/ JCode Required
    Documented Diagnosis: Yes
    Criteria includes risk factor for developing FN: No

  • Step Therapy: Neutropenia:
    ST Single Brand