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Prior Authorization Update for Neulasta® and Udenyca® (pegfilgrastim) Effective March 1, 2023

Audience: Participating Radiologists

We would like to provide advance notice regarding prior authorization requirements for Neulasta and Udenyca (pegfilgrastim) when billed under the member’s medical benefit. This update is effective March 1, 2023, and applies to all lines of business.

To ensure accurate prescribing and correct claim submissions, please follow the requirements outlined below and share this important information with your billing office/billing service and anyone within your practice who should be aware.

Neulasta® and Udenyca® (pegfilgrastim)

As of March 1, 2023, Neulasta and Udenyca will require prior authorization to ensure appropriate use. Neulasta and Udenyca will continue to remain the preferred pegfilgrastim agents. This change impacts new starts only and does not apply to existing users.

Billing Requirements

Neulasta

Prior Authorization Required (starting 3/1/23)

Preferred Drug

Udenyca

Prior Authorization Required (starting 3/1/23)

Preferred Drug

Fulphila®

Prior Authorization Required

Non-Preferred Drug

Nyvepria™

Prior Authorization Required

Non-Preferred Drug

Ziextenzo®

Prior Authorization Required

Non-Preferred Drug

Fylnetra®

Prior Authorization Required

Non-Preferred Drug

Rolvedon™

Prior Authorization Required

Non-Preferred Drug

When submitting a prior authorization request for these drugs, please include all of the following relevant and required clinical information:

  • Diagnosis
  • If requesting a non-preferred drug, please provide clinical justification as to why Neulasta or Udenyca are not the best choice for your patient

Medical Benefit Billing Requirements (preferred drugs)

J-code/Q-code

NDC

J2506 Injection, pegfilgrastim, excludes biosimilar, 0.5 mg

Neulasta Onpro 6mg/0.6ml Solution:

  • 55513-0192-01

Neulasta 6mg/0.6ml Solution:

  • 5513-0190-01

Q5111 Injection, Pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg

Udenyca 6mg/0.6ml Solution Prefilled Syringe:

  • 70114-0101-01

If you have questions or concerns, please contact your Provider Relations representative.

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