Non-Preferred Pegfilgrastim Products (Revised)

By January 1, 2026: Billing and prior authorization teams must implement the following: (1) Update billing system to require prior authorization for all pegfilgrastim biosimilar claims (J2505-J2510 and related HCPCS codes) submitted to Humana South Carolina Medicaid; (2) Modify authorization criteria in PA system to enforce the mandatory requirement that patients demonstrate previous treatment failure or documented intolerance to BOTH Fulphila (pegfilgrastim-jmdb) and a Neulasta (pegfilgrastim) product before any non-preferred biosimilar is approved; (3) For febrile neutropenia prophylaxis claims, ensure PA requests include documentation that the patient has a non-myeloid malignancy diagnosis and meets ONE OR MORE of the three chemotherapy risk criteria (>20% FN risk, OR 10-20% risk with ≥1 risk factor, OR <10% risk with ≥2 risk factors); (4) Add claim-level edits to reject requests for same-day administration with myelosuppressive chemotherapy (except for on-body injector products) and to prevent approval for dosing more frequent than every two weeks; (5) Providers and clinical staff must ensure all PA requests include documented evidence of prior Fulphila and Neulasta treatment/intolerance and appropriate clinical risk stratification per ASCO/NCCN guidelines; (6) Update encounter templates and PA request forms to prompt for these new documentation requirements. Failure to obtain prior authorization before dispensing will result in claim denials.