MedicaidPrior AuthHigh impact
Preferred Pegfilgrastim Products: Neulasta/Neulasta Onpro, Fulphila (Revised)
Humana·SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicaid South Carolina has updated prior authorization requirements for pegfilgrastim products (Neulasta, Neulasta Onpro, Fulphila) used for febrile neutropenia prophylaxis in cancer patients. The policy establishes specific criteria based on chemotherapy regimen risk levels and patient risk factors, with exclusions for same-day administration with chemotherapy.
Action Required
Before January 1, 2026: Billing team must implement prior authorization requirements for all pegfilgrastim products (Neulasta, Neulasta Onpro, Fulphila) for South Carolina Medicaid patients. Update billing system to flag these medications and ensure providers document: 1) Non-myeloid malignancy diagnosis, 2) Chemotherapy regimen febrile neutropenia risk percentage, 3) Patient risk factors if applicable, 4) Confirm no same-day administration with chemotherapy (except wearable devices). Claims without proper prior authorization will be denied.