Non-preferred Pegfilgrastim Products: Armlupeg, Fylnetra, Nyvepria, Stimufend, Ziextenzo (Revised)

REQUIREMENTS: By January 1, 2026: Billing team must implement prior authorization requirements in billing software for HCPCS codes J2505, J2506, J2507, J2508, and J2509 (non-preferred pegfilgrastim biosimilars) for all Medicare Advantage members. Specific Actions: 1. Update billing system to require prior authorization requests for these five HCPCS codes before claim submission 2. Configure system to distinguish between Medicare Part B (medical benefit) and Part D (pharmacy benefit) requests, as step-therapy requirements differ: - Part B: Requires documentation of previous treatment with OR intolerance to TWO preferred products (Neulasta, Fulphila, Udenyca), UNLESS request is continuation of therapy within past 365 days - Part D: Requires documentation of previous treatment with OR intolerance to ONE preferred product (Udenyca) 3. Create prior authorization templates requiring providers to document: - Diagnosis (non-myeloid malignancy or acute radiation exposure or stem cell mobilization) - Febrile neutropenia risk assessment per ASCO/NCCN guidelines - Applicable risk factors if chemotherapy FN risk is 10-20% or less than 10% - Previous therapy failures or intolerances with specific drug names 4. Flag and reject claims for same-day administration with myelosuppressive chemotherapy (unless product worn on body) 5. Flag and reject claims for dosing more frequent than once every two weeks 6. Update provider communication materials explaining new step-therapy requirements Who: Billing team, EMR/billing system administrator, providers Where: Billing software rules engine, prior authorization templates, provider portals Consequences: Claims submitted without proper prior authorization or step-therapy documentation will be denied by Humana Medicare Advantage plans.