| 447 | Pre-Stem Cell Transplant Mobilization:
For Peripheral Blood Progenitor Cell (PBPC) collection for peripheral stem cell transplant as treatment for malignant disease.
Approval for Neupogen 300mcg and 480mcg vial format only. |
| | LU Authorization Period: 14 days |
| | NOTE: Reimbursement is limited to the duration required per the treatment protocol and to prescriptions written by an oncologist or hematologist. |
| 500 | For pediatric patients (less than 18 years age) who are unable to achieve the appropriate dose of granulocyte colony-stimulating factor with the formulary listed formats of pre-filled syringes.
Approval for Neupogen 300mcg vial format only. |
| | LU Authorization Period: 1 year |
| 501 | For patients who are unable to use available formats of Grastofil due to a documented latex allergy.
Approval for Neupogen 300mcg and 480mcg vial format only. |
| | LU Authorization Period: Indefinite. |
