Filgrastim (Neupogen, Nivestrym, Zarxio)

Covered: filgrastim for non‑oncology indications only—symptomatic severe chronic neutropenia (congenital, cyclic, idiopathic; FDA‑approved), HIV/AIDS‑associated neutropenia, and drug‑induced (non‑chemotherapy) agranulocytosis/neutropenia; oncology use is excluded. Key requirements: documentation of diagnosis and symptoms for chronic neutropenia, appropriate specialist prescription/consult (hematologist for chronic; infectious disease/hematology/HIV specialist for HIV), duration limits (approve up to 6 months for chronic, 4 months for HIV, 1 month for drug‑induced), and dosing caps (chronic ≤12 mcg/kg/day SC; HIV and drug‑induced ≤10 mcg/kg/day SC).

"For HIV/AIDS-associated neutropenia: evidence that filgrastim is prescribed by or in consultation with a physician specializing in infectious diseases, a hematologist, or a physician who specialize..."

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