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Important Notification Regarding Granulocyte Colony-Stimulating Factors Medical Policy For Commercial Members*

The Food and Drug Administration (FDA) has approved biosimilar products that can be utilized in place of reference drugs in most clinical circumstances. Biosimilar products offer additional safe and cost-effective options.
The FDA has approved several biosimilars for the originator product, Neulasta® (pegfilgrastim). Neulasta and its biosimilar products, Fulphila™ (pegfilgrastim-jmdb), Udenyca® (pegfilgrastim-cbqv), Ziextenzo™ (pegfilgrastim-bmez), and Nyvepria™ (pegfilgrastim-apgf) are part of the Blue Cross Blue Shield of North Dakota (BCBSND) Granulocyte Colony-Stimulating Factors medical policy for Commercial Members.

Effective January 1, 2023, Blue Cross Blue Shield of North Dakota (BCBSND) will start requiring precertification for pegfilgrastim products and is updating the Granulocyte Colony-Stimulating Factors medical policy to include pegfilgrastim preferred agents. Please see the table below for a list of preferred and non-preferred pegfilgrastim agents. Non-preferred agents that do not meet the updated medical policy criteria may not have benefit coverage and therefore may not be reimbursed. The Granulocyte Colony-Stimulating Factors medical policy will be updated to reflect these changes and will be available for review on bcbsnd.com before September 1, 2022.

To obtain coverage of a Preferred or Non-Preferred Agent on or after January 1, 2023, a precertification request will be needed and approved based on the updated medical policy criteria.

Preferred Agents (effective 1/1/2023)

Non-Preferred Agents (effective 1/1/2023)

Fulphila (pegfilgrastim-jmdb) (Q5108)

Neulasta/Neulasta Onpro (pegfilgrastim) (J2506)

Ziextenzo (pegfilgrastim-bmez) (Q5120)

Nyvepria (pegfilgrastim-apgf) (Q5122)

Udenyca (pegfilgrastim-cbqv) (Q5111)

* This change does not apply to Medicaid Expansion members