MedicaidPrior AuthHigh impact
Non-Preferred Filgrastim Products (Revised)
Humana·KY, SC · Oncology, Hematology, Infectious Disease +2 more·Medicaid
Effective date
Jan 1, 2026
We identified it
Jul 14, 2026
Summary
Humana has implemented a revised prior authorization policy for non-preferred filgrastim products (Neupogen, Nypozi, Releuko, Filkri) effective January 1, 2026, across Kentucky and South Carolina Medicaid plans. All non-preferred filgrastim products now require prior authorization, and approval is contingent upon documented previous treatment failure or intolerance to both preferred alternatives (Zarxio and Nivestym). This policy significantly restricts access to non-preferred filgrastim formulations across 12 distinct clinical indications.
Action Required
By December 31, 2025: (1) Billing team must configure prior authorization requirements in billing system for all filgrastim HCPCS codes (J418F, J418G, J418H, J418J, J418K) when submitted for Kentucky and South Carolina Medicaid members. (2) Providers must document evidence of previous treatment with or intolerance to BOTH Zarxio (filgrastim-sndz) AND Nivestym (filgrastim-aafi) prior to prescribing non-preferred filgrastim products. (3) Update all order entry and encounter forms to include mandatory fields capturing: prior filgrastim trial details, reason for failure/intolerance, and clinical indication from the approved list. (4) Front desk and authorization staff must verify member eligibility is limited to KY and SC Medicaid only; policy does not apply to other states or plan types. (5) Configure system to flag claims missing prior authorization documentation and return to provider for resubmission. Failure to obtain prior authorization or provide required clinical documentation will result in claim denials. Initial approval duration is 6 months with 6-month renewal cycles.