Colony Stimulating Factors Pegylated
| Covered Uses: | All FDA-approved indications not otherwise excluded from Part D. |
| Exclusion Criteria: | Combination therapy with either 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. Patient must be unable to receive daily (or more frequent) injections of Neupogen or Leukine due to noncompliance or inconvenience. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: |
Last Modified on 12/19/2012