All PlansPrior AuthHigh impact
Pegfilgrastim (Neulasta®); Pegfilgrastim-unne ( Armlupeg® ); Pegfilgrastim-pccg (Ennumo™); Pegfilgrastim-jmdb (Fulphila®); Pegfilgrastim-pbbk (Fylnetra®); Pegfilgrastim-apgf (Nyvepria™); Pegfilgrastim-fpgk (Stimufend®); Pegfilgrastim-cbqv (Udenyca®); Pegfilgrastim-bmez (Ziextenzo™)
BCBS Tennessee·TN · Oncology, Hematology, Radiation Oncology·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a new comprehensive medical policy covering 9 pegfilgrastim biosimilar products used to prevent febrile neutropenia in cancer patients receiving chemotherapy and for hematopoietic acute radiation syndrome. The policy establishes coverage criteria based on chemotherapy risk stratification, requires documentation of diagnosis and regimen, and mandates step therapy requirements. CRITICAL: Do not implement until 10/31/2026.
Action Required
By October 31, 2026: (1) Billing team must update authorization workflows to require step therapy verification per the referenced guide (https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf) for all pegfilgrastim products (J2505-J2513). (2) Configure billing system to enforce coverage criteria: deny claims if chemotherapy regimen risk is <20% without documented high-risk factors, or <10% risk without 2+ patient-related risk factors. (3) Update prior authorization templates to require documentation of: member diagnosis, specific chemotherapy regimen, and FN risk assessment per Appendices A-C. (4) Providers must document chemotherapy regimen details and patient risk factors on all requests. (5) Update claim edits to prevent payment when medications are combined with other CSF agents, given concurrently with radiation, or used with weekly chemo regimens. (6) Modify authorization duration from unlimited to 6-month increments. Non-compliance will result in claim denials and payment recovery.