Amgen - Medical Professionals

Coverage and Reimbursement

Medicaid

Medicare

Private Payors, HMOs, PPOs, Blue Cross®/Blue Shield®, and Pharmacy Benefit Plans

Medicaid

Physician Office

Medicaid coverage and reimbursement varies by state.

Many state Medicaid programs cover and reimburse drugs when administered in the physician office.

Some state Medicaid programs may channel drugs through Medicaid-approved retail pharmacies or may require patients to obtain the drug through a pharmacy and bring it to the physician office for administration
Other state Medicaid agencies may allow the physician to purchase, administer, and bill for a drug

Many Medicaid programs also pay for the administration of the drug, but may require providers to secure prior authorization before the administration of Neulasta® (pegfilgrastim).

When Neulasta® is used in the physician office setting, the Neulasta® J2505 code is used.

Hospital Outpatient

Some Medicaid programs allow coverage for Neulasta® administered in the hospital outpatient department.

Generally, reimbursement is based on costs or charges. However, some states may reimburse for services on a per diem basis, which typically includes drugs like Neulasta®.
Some programs limit outpatient benefits to a specified dollar amount per year, per patient

Hospital Inpatient

Medicaid programs should allow coverage for Neulasta® administered in the hospital inpatient setting.

In this setting, some states reimburse on a per diem basis, others use DRGs (like Medicare), and others pay based on allowable costs
Some programs may limit inpatient benefits by capping the number of inpatient days per year, per patient, by setting, or by a specified dollar amount per year, per patient

Pharmacy

State Medicaid programs are likely to cover Neulasta® for its approved indication when dispensed in the retail pharmacy.

Certain states may have prior authorization requirements for Neulasta®.

Some states restrict the number of monthly prescriptions for Neulasta®

Medicaid reimbursement for Neulasta® varies by state.

The national drug code (NDC) for Neulasta® will be required by most Medicaid agencies to determine reimbursement
Currently for pharmacy-dispensed products, Medicaid payment may be based on either the AWP minus a percentage or the wholesale acquisition cost (WAC) plus a percentage; however, Medicaid agencies may switch to Average Manufacturer Price (AMP)-based reimbursement later in 2007
Pharmacies generally also receive a dispensing fee, which varies from state to state

Medicaid coverage, coding, and payment policies for Neulasta® vary by setting and by state. The Reimbursement Connection® (1-800-272-9376) can assist you with identifying your state's policies and coding requirements.

Neulasta® Indication and Important Product Safety Information

Neulasta® is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anticancer drugs associated with a clinically significant incidence of febrile neutropenia.

Important Product Safety Information

Splenic rupture (including fatal cases), acute respiratory distress syndrome, and sickle cell crises have been reported. Allergic reactions, including anaphylaxis, have also been reported. The majority of these reactions occurred upon initial exposure. However, in rare cases, allergic reactions, including anaphylaxis, recurred within days after discontinuing anti-allergic treatment.
In a placebo-controlled trial, bone pain occurred at a higher incidence in Neulasta®-treated patients as compared to placebo-treated patients (31% vs 26%). The most common adverse events reported in either placebo- or active-controlled trials were consistent with the underlying cancer diagnosis and its treatment with chemotherapy, with the exception of bone pain.

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