Effective August 1, 2023, Blue Cross Blue Shield of North Dakota (BCBSND) is updating the Granulocyte Colony-Stimulating Factors medical policy.
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.
Existing precertification approvals will still be honored for the duration of the original approval dates given.
Preferred Agents | Non-Preferred Agents |
Fulphila | Fylnetra (pegfilgrastim-pbbk) (Q5130) Nyvepria (pegfilgrastim-apgf) (Q5122) Rolvedon (eflapegrastim-xnst) (J1449) Stimufend (pegfilgrastim-fpgk) (Q5127) Udenyca (pegfilgrastim-cbqv) (Q5111) Ziextenzo (pegfilgrastim-bmez) (Q5120) |
* This change does not apply to Medicaid Expansion members
