Does Q5125 require prior authorization?

Yes, Q5125 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5125?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q5125`, Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37176 for White Cell Colony Stimulating Factors; refer to LCD L37176 for specific coverage criteria, indications, and limitations.

Key Coverage Criteria

Medically necessary use of Leukine, Neupogen, Nivestym, Nypozi, Releuko, and Zarxio for bone marrow/stem cell transplant indications when: (a) non-myeloid malignancies with myeloablative chemotherapy followed by BMT; or (b) mobilization of hematopoietic progenitor cells into peripheral blood for leukapheresis; or (c) PSCT after myeloablative chemotherapy.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Medically necessary when the drug is FDA‑approved and administered in accordance with FDA labeling for an oncologic indication.
Medically necessary when the drug has an NCCN category 1, 2A, or 2B recommendation or is listed in the NCCN Drugs & Biologics Compendium.
Oncology medications are medically necessary if (a) the drug is FDA-approved for the oncologic indication and used per FDA labeling, OR (b) the drug has an NCCN Category 1/2A/2B indication per NCCN Guidelines or NCCN Compendium.

13 Active Policies

MODA-FILGRASTIMS-03DC48CF13, Short-Acting Granulocyte Colony Stimulating Factors (SA-gCSF): Filgrastim (Neupogen); Filgrastim-aafi (Nivestym); Filgrastim-sndz (Zarxio); Filgrastim-ayow (Releuko); Tbo-Filgrastim (Granix); Filgrastim-txid (Nypozi)

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

EVICORE-MEDICAL_DRUG-4E919098646A, Filgrastim Products (Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Filkri) Non-oncologyEffective 10/01/2026

EVICORE-MEDICAL_DRUG-A471D001CE8C, Filgrastim Products (Neupogen, Nivestym, Nypozi, Releuko, Zarxio) Non-oncology

A56748, Billing and Coding: White Cell Colony Stimulating Factors

UHC-POL-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

SUREST-POL-SUREST-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

`Q5125`, Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

Q5125, Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`Q5125`, Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram