White Blood Cell Colony Stimulating Factors – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers FDA‑approved G‑CSF and GM‑CSF agents for specified indications (e.g., BMT/PSCT including PBPC mobilization — note Neulasta is not indicated for mobilization per label — AML induction/consolidation, primary/secondary prophylaxis of chemo‑induced febrile neutropenia, treatment of FN only under defined high‑risk off‑label criteria, severe chronic neutropenia, and hematopoietic acute radiation syndrome); any product not listed is non‑preferred until review. Coverage requires adherence to product‑preference and step/try‑and‑fail rules (Neulasta/Udenyca preferred for pegfilgrastim; Zarxio/Nivestym preferred for filgrastim), documentation of diagnosis, prior trial of preferred agent or documented intolerance/contraindication with physician attestation, relevant labs (ANC, bilirubin, CrCl), and dosing per FDA labeling.

"Bone Marrow/Stem Cell Transplant: Patient has non-myeloid malignancies and is undergoing myeloablative chemotherapy followed by autologous or allogeneic bone marrow transplant (BMT)."