The following products are included in this PA program (formulary specific):
MAPD and HC Enhanced formularies: Fulphila, Granix, Leukine, Nivestym, Udenyca, Udenyca Onbody, Ziextenzo
Basic formulary: Granix
Prior Authorization Criteria for Approval
The formulary medication will be approved when ALL of the following are met:
- The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
AND - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., oncologist, hematologist, infectious disease) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
Length of Approval: 6 months
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