In addition, for treatment of moderate to severe rheumatoid arthritis: Failure of, or contraindication/intolerance to all of the following: Methotrexate AND at least 1 other oral DMARD (sulfasalazine, hydroxychloroquine or leflunomide) for at least 3 months (in combination or each as monotherapy) At trial 2 of the following: Enbrel or Humira for three consecutive months Colony-Stimulating For Patients who meet the following: Initial Approval: Factors (CSF) Prescribed for a medically accepted indication/diagnosis Neupogen Neupogen, Neulasta Prescribed by hematologist and/or oncologist, or specialist per associated 14 day course per Neumega diagnosis/indication chemotherapy Leukine In addition, for Neupogen: cycle Chemotherapy-induced neutropenia Refills if indicated Chemotherapy regimen has approximately 20% risk of febrile neutropenia Neulasta ≥ 1 dose per 21 days OR Refills as indicated Member is at high-risk for neutropenic complications (e.g., age > 65, pre-existing neutropenia or tumor involvement in the bone marrow, infection, renal or liver Neumega impairment, other serious co-morbidities) Up to 21 days’ Administered 24 72 hours after completion of chemotherapy – supply Patient is not receiving concurrent chemotherapy and radiation therapy Refills if number of Treatment of neutropenia cycles provided Severe chronic congenital neutropenia, cyclic neutropenia, or idiopathic Leukine neutropenia AML, bone marrow HIV-induced or drug-induced neutropenia in immunosuppressed patients transplant: up to Patient has evidence of inadequate bone marrow reserve (e.g., recurrent 42 days fevers, splenomegaly, mucosal ulcers, abdominal pain) All other OR indications: 30 days Patient is at high risk for the development of serious bacterial infection (e.g., primarily severe neutropenia, indwelling venous catheters, prior serious infections) Renewal: OR Patient has a documented bacterial infection
In addition, for treatment of moderate to severe rheumatoid arthritis: Failure of, or contraindication/intolerance to all of the following: Methotrexate AND at least 1 other oral DMARD (sulfasalazine, hydroxychloroquine or leflunomide) for at least 3 months (in combination or each as monotherapy) At 2 of the following: Enbrel or Humira for three consecutive months Colony-Stimulating Factors (CSF) Neupogen, Neulasta Neumega Leukine For Patients who meet the following: Prescribed for a medically accepted indication/diagnosis Prescribed by hematologist and/or oncologist, or specialist per associated diagnosis/indication In addition, for Neupogen: Chemotherapy-induced neutropenia Chemotherapy regimen has approximately ≥ 20% risk of febrile neutropenia OR Member is at high-risk for neutropenic complications (e.g., age > 65, pre-existing neutropenia or tumor involvement in the bone marrow, infection, renal or liver impairment, other serious co-morbidities) Administered 24 – 72 hours after completion of chemotherapy Patient is not receiving concurrent chemotherapy and radiation therapy Treatment of neutropenia Severe chronic congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia HIV-induced or drug-induced neutropenia in immunosuppressed patients Patient has evidence of inadequate bone marrow reserve (e.g., recurrent fevers, splenomegaly, mucosal ulcers, abdominal pain) OR Patient is at high risk for the development of serious bacterial infection (e.g., primarily severe neutropenia, indwelling venous catheters, prior serious infections) OR Patient has a documented bacterial infection Initial Approval: Neupogen 14 day course per chemotherapy cycle Refills if indicated Neulasta 1 dose per 21 days Refills as indicated Neumega Up to 21 days’ supply Refills if number of cycles provided Leukine AML, bone marrow transplant: up to 42 days All other indications: 30 days Renewal: trial
MMIC-PA-SMI-Guidelines.docx