MA08.130j, Filgrastim (Neupogen®) and Related Biosimilars, and Tbo-filgrastim (Granix®)

REQUIREMENTS: - By April 20, 2026: Billing team must update billing system to enforce preferred product rules: filgrastim-sndz (Zarxio) and filgrastim-aafi (Nivestym) are preferred; all other filgrastim products including newly added filgrastim-laha (Filkri) are nonpreferred and require prior authorization documentation of contraindication, intolerance, or inadequate response to preferred products. - By April 20, 2026: Update claims processing logic to map filgrastim-laha claims to HCPCS code Q5172 (or C9399/J3590 as applicable). Ensure billing software recognizes Q5172 as a valid but nonpreferred product code. - Before April 20, 2026: Train billing and prior authorization staff on expanded coverage indications including CAR-T cell therapies, lifileucel (Amtagvi), pediatric Hodgkin lymphoma, Burkitt lymphoma, diffuse large B-cell lymphoma, and updated chemotherapy regimens (Melphalan PHP, DCEP, FLOT, docetaxel, FOLFIRINOX). - Before April 20, 2026: Update provider documentation templates and prior authorization request forms to align with new NCCN-recommended indications to support medical necessity claims. - Immediate ongoing: For any filgrastim-laha (Filkri) claims received: Verify prior authorization documentation; if unavailable or insufficient, deny claim and notify provider that nonpreferred product requires documented contraindication/intolerance to preferred products or prior failed therapy. - Failure to implement preference rules and prior authorization requirements will result in claim denials and member cost-sharing issues.