MedicaidPrior AuthHigh impact
Non-Preferred Pegfilgrastim Products (Revised)
Humana·KY · Oncology, Hematology, Internal Medicine·Medicaid
Effective date
Jan 1, 2026
We identified it
Sep 24, 2026
Summary
Humana Kentucky Medicaid revised its prior authorization policy for non-preferred pegfilgrastim biosimilar products (Armlupeg, Fulphila, Fylnetra, Nyvepria, Stimufend, Udenyca, and Ziextenzo) effective January 1, 2026. The policy requires prior authorization for these products when used for febrile neutropenia prophylaxis, acute radiation syndrome, or stem cell mobilization, with specific clinical criteria including prior Neulasta treatment/intolerance, non-myeloid malignancy diagnosis, and chemotherapy febrile neutropenia risk stratification per ASCO/NCCN guidelines.
Action Required
By December 20, 2025: Billing team and clinical staff must implement prior authorization workflow for all non-preferred pegfilgrastim biosimilar HCPCS codes (J2505-J2512) for Kentucky Medicaid members. Update billing system to flag these products for mandatory PA submission before claim processing. Ensure prior auth requests include: (1) documentation of prior Neulasta (pegfilgrastim) treatment or documented intolerance; (2) ICD-10 diagnosis confirming non-myeloid malignancy; (3) current chemotherapy regimen with febrile neutropenia risk assessment per ASCO/NCCN guidelines; (4) risk factor documentation if FN risk is 10-20% or <10%; (5) confirmation that product will not be administered same-day with chemotherapy (except for on-body injector products). Add to encounter templates a checklist confirming Exclusion #1 (not same-day with chemotherapy unless on-body device) and Exclusion #2 (not more frequent than every 2 weeks). Claims submitted without prior authorization will be denied. PA approval duration is 6 months or per clinical review.