White Cell Colony Stimulating Factors
JJ · Effective Jun 12, 2017
3 active Medicare policies list Q5101, and 23 commercial payer policies list it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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JJ · Effective Jun 12, 2017
JM · Effective Jun 12, 2017
National · Effective Jul 1, 2026
23 policies from 13 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
Showing 10 of 11 · All EviCore by Evernorth policies
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Filgrastim (Neupogen , Nivestym, Zarxio, Releuko) Non-oncologyEffective 03/01/2025 - 03/31/2025 | Mar 1, 2025 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 01/01/2021 - 11/30/2021 | Jan 1, 2021 | Prior auth requiredInferred from policy title |
| Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2018 - 11/30/2019 | Dec 1, 2018 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2019 - 12/31/2020 | Dec 1, 2019 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2021 - 11/30/2022 | Dec 1, 2021 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
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| Filgrastim (Neupogen, Nivestym, Nypozi, Releuko, Zarxio) Non-oncologyEffective 04/01/2025 - 03/31/2026 | Apr 1, 2025 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)_Non-oncologyEffective 11/01/2023 - 10/31/2024 | Nov 1, 2023 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
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| Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)_Non-oncologyEffective 11/01/2024 - 02/28/2025 | Nov 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)Effective 12/01/2022 - 10/31/2023 | Dec 1, 2022 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Filgrastim Products (Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Filkri) Non-oncologyEffective 10/01/2026 | Not recorded | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Donor Lymphocyte Infusion | Sep 13, 2023 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Q4 - 2026 JHP MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Filgrastim (Neupogen, Nivestym, Zarxio) – Minnesota Health Care Programs | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| Granulocyte Colony Stimulating Factor (G-CSF - Neupogen, Neulasta, Granix, Zarxio, Fulphila, Nivestym, Udenyca, Ziextenzo, Nyvepria) and Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF - Leukine) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| 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) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5101 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |