Colony Stimulating Factors

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for neutropenia due to other drugs and chemotherapy, AIDS/HIV, severe chronic neutropenia, and myelodysplasia.
Exclusion Criteria:	Combination therapy with Neulasta, Neupogen or Leukine.
Required Medical Information:	Patient has experienced neutropenia from previous chemotherapy OR for patient is considered to be at high risk for the development of neutropenia. High risk for neutropenia is define by pre-existing neutropenia due to disease, chemo regimen associated with a high incidence of febrile neutropenia, extensive prior chemotherapy, previous radiation to areas containing large amounts of bone marrow, pts at high risk for infection (such as advanced cancer, decreased immune function, open wounds, and active infection). Coverage is provided for: Myelodysplasia when ANC is less than or equal to 1000/mm3, Severe chronic neutropenia (i.e., Neutropenic disorder, cyclic neutropenia) when ANC is less than or equal to 1500/mm3, bone marrow transplant when ANC is less than or equal to 1000/mm3, Current or post peripheral blood progenitor cell (PBPC) mobilization/transplantation (i.e., harvesting of peripheral blood stem cells) when ANC is less than or equal to 1500/mm3
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:

Last Modified on 12/19/2012