White Cell Colony Stimulating Factors
JJ · Effective Jun 12, 2017
3 active Medicare policies list Q5120, and 13 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 Oct 1, 2025
13 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.
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Donor Lymphocyte Infusion | Sep 13, 2023 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 |
| Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Pegfilgrastim (Neulasta); Pegfilgrastim-jmdb (Fulphila); Pegfilgrastim--pbbk (Fylnetra); Pegfilgrastim- apgf (Nyvepria); Pegfilgrastim-fpgk (Stimufed); Pegfilgrastim-cbqv (Udenyca); Pegfilgrastim-bmez (Ziextenzo) | Dec 1, 2016 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Cigna MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List | Not recorded | Prior auth required |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| 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 Q5120 |
|---|---|---|
| Long-Acting Granulocyte Colony Stimulating Factors (LA-GCSF): Fulphila; Fylnetra; Neulasta; Nyvepria; Pegfilgrastimfpgk; Rolvedon; Ryzneuta; Stimufend; Udenyca; Ziextenzo | 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 Q5120 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |
| Policy | Effective | Status of Q5120 |
|---|---|---|
| White Blood Cell Colony Stimulating Factors | Sep 1, 2026 | Covered |