Given the growing concerns about the shortage and availability of Ziextenzo (pegfilgrastim-bmez) in the Colony Stimulating Factors therapeutic class, DHS is changing the status of Fulphila (pegfilgrastim-jmdb) to preferred effective 7/12/2023 on the statewide PDL. Ziextenzo (pegfilgrastim-bmez) will be non-preferred effective 7/12/2023. Jefferson Health Plans has also instructed eviCore, our UM vendor for chemotherapy, to allow Fulphila in addition to the other white cell stimulating factors available as preferred agents.

Please note this class of medications will still require prior authorization for preferred products. This update is for Medicaid and CHIP lines of business as “Fulphila® is already preferred for our Medicare line of business. A list of the preferred Colony stimulating Factor products are noted below:

Medicaid and CHIP

Colony Stimulation Factors (Preferred Agents):

Granix (tbo-filgrastim) Syringe

Granix (tbo-filgrastim) Vial

Neupogen (filgrastim) Syringe

Neupogen (filgrastim) Vial

Nyvepria (pegfilgrastim-apgf) Syringe

Releuko (filgrastim-ayow) Syringe

Releuko (filgrastim-ayow) Vial

Fulphia (pegfilgrastim-jmdb) Syringe

Medicare Part B

Hematologic, Neutropenia Colony Stimulating Factors – Long Acting (Preferred Agents):

Udenyca (pegfilgrastim-cbqv)

Nyvepria (pegfilgrastim-apgf)

Fulphia (pegfilgrastim-jmdb) Syringe