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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONLeukine is a recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) that is produced by recombinant DNA technology in yeast expression system. Neupogen is a human granulocyte colony-stimulating factor (G-CSF), produced by recombinant DNA technology. Neupogen is produced by E. coli bacterium into which has inserted the human granulocyte colony-stimulating factor gene.
POLICYLeukine or Neupogen will be approved when one of the following criteria are met:
If criteria are met, authorization for therapy will be one month.
Leukine or Neupogen will be approved when all of the following criteria are met:
If criteria are met, authorization for therapy will be one month or duration of chemotherapy regimen.
Neupogen will be approved when one of the following criteria are met:
If criteria is met, authorization for therapy will be issued for duration of therapy.
POLICY EXCEPTIONSLeukine/Neupogen prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY01/01/2014: New policy added.
SOURCE(S)Leukine® Prescribing Information
Neupogen® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.