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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that G-CSF pegfilgrastim (Neulasta) and the biosimilar Fulphila are indicated for the following: 
 
 Patients with Cancer Receiving Myelosuppressive Chemotherapy and/or Immunotherapy: to decrease the 
incidence of infection, as manifested by febrile neutropenia (FN), in patients with non-myeloid malignancies 
receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of severe FN. 
 
 Patients with Hematopoietic SubSyndrome of Acute Radiation Syndrome: to increase survival in patients 
acutely exposed to myelosuppressive doses of radiation 
 
Neulasta and biosimilars are not indicated for the mobilization of peripheral blood progenitor cells for 
hematopoietic stem cell transplantation. 
 
In addition to the FDA-approved uses, coverage will be extended when any of the drugs- Filgrastim 
(Neupogen) or Filgrastim-sndz biosimilar (Zarxio), Pegfilgrastim (Neulasta), Sargramostim (GM-CSF, 
Leukine), or Tbo-Filgrastim (Granix) and biosimilars are used as adjunctive treatment when any of the 
conditions listed below are present. 
 
Any of the following conditions may be an indication for adjunctive treatment: 
 
1. Expected prolonged (greater than 10 days) and profound (less than 0.1 x 109/L) neutropenia; 
2. Age greater than 65 years; 
3. Uncontrolled primary disease; 
4. Pneumonia; 
5. Hypotension and multi organ dysfunction (sepsis syndrome); 
6. Invasive fungal infection; or 
7. Hospitalized at the time of the development of fever. 
 
Pegfilgrastim (Neulasta) and Biosimilars: 
 A. In an individual with ALL after completion of the first few days of initial induction chemotherapy or first 
post-remission course of chemotherapy; or 
 
B. In an individual with MDS with severe neutropenia (ANC less than or equal to 500 mm3 or experiencing 
recurrent infection; or 
 
C. In an individual receiving dose dense therapy (treatment given more frequently, such as every 2 weeks 
instead of every 3 weeks) for adjuvant treatment of breast cancer, or other malignancies for which dose dense 
chemotherapy is an accepted treatment option. If a patient is on a dose dense 14-day chemotherapy cycle, it 
would be acceptable to administer Neulasta outside of the 14-day before and 24-hour after rule for 
chemotherapy. Neulasta would typically be administered on the second day of a 14day dose dense 
chemotherapy cycle. The medical record should clearly indicate that the patient is on a 14-day dose dense 
chemotherapy cycle regimen; or 
 
D. After HPCT/HSCT for the following indications: 
 
 To promote myeloid reconstitution; or 
 
 When engraftment is delayed or has failed. 
 
You can find these rules in Local Coverage Determination (LCD): White Cell Colony Stimulating Factors 
(L37176). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.