Q5122 Inj, nyvepriaInjection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg
Q5122 payment limit: $141.289 per 0.5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: 8% of reference add-on applied.
00069-0324-01 Nyvepria, Pfizer Inc: 12 billing units per package (1 CARTON in 1 CARTON / 1 SYRINGE in 1 CARTON / .6 mL in 1 SYRINGE)Status E: excluded from the PFS by regulation.
142 of 142 payer prior-auth lists that name Q5122 require prior authorization or set conditions: Aetna, Arkansas Blue Cross and Blue Shield, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, and others.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth required | Non-preferred product | Jan 1, 2024 | Medical Benefit Pharmacy Prior Approval List |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Oncology dx: eviCore | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Non-oncology dx: AZ Blue | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth required | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | eviCore-delegated groups, all sites | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Aetna | Medicare Advantage | All | prior auth required | Step therapy applies | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) |
| Aetna | Medicare Advantage | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Commercial | All | prior auth required | Oct 1, 2026 | Participating provider precertification list for Aetna® | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2021 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2021 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2021 | Master Precertification List (For Health Care Providers) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | Step therapy | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi |
| Humana | Humana D-SNP (FL) | FL | prior auth required | New PA requirement; Step therapy | Jul 1, 2026 | H1036-280 Humana Fully Integrated Florida prior authorization and notification list |
| Humana | Humana D-SNP (IL) | IL | prior auth required | Step therapy | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IN) | IN | prior auth required | Step therapy | Jan 1, 2027 | Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: |
| Humana | Humana D-SNP (MI) | MI | prior auth required | New PA requirement; Step therapy | Oct 14, 2026 | Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) |
| Humana | Humana D-SNP (SC) | SC | prior auth required | New PA requirement; Step therapy | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (VA) | VA | prior auth required | New PA requirement; Step therapy | Jul 1, 2026 | Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) |
| Humana | Humana Healthy Horizons | KY | prior auth required | Oct 7, 2026 | Humana Healthy Horizons in Kentucky Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | LA | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | OH | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Ohio prior authorization and notification List | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List | |
| Humana | Humana Healthy Horizons | SC | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in South Carolina prior authorization and notification list | |
| Humana | Humana Healthy Horizons | VA | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list | |
| Humana | Humana MA and D-SNP | All | prior auth required | Step therapy | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 | |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 | |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth required | cancer dx via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | cancer dx via NCH | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 | |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 | |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 | |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 | |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 | |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 | |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | cancer dx via Evolent | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | site of care: outpatient | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | site of care: outpatient | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth under conditions | 2 For some codes, prior authorization is required for both oncology and non-oncology Dx.. For oncology Dx, please see Cancer supportive care section above. For non-oncology Dx submit online using the | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | 2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| Oxford Health Plans | Oxford Health Plans | All | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Prior Authorization Requirements for Oxford Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth required | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 | |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans Prime / RAE | CO | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Rocky Mountain Health Plans PRIME Effective October 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth under conditions | site of care: outpatient | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
| Surest | Surest health plans | All | prior auth under conditions | 2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 |
| Surest | Surest health plans | All | prior auth under conditions | *Codes J1442, J1447, | Oct 1, 2026 | Prior Authorization Requirements for Surest Effective October 1, 2026 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 | |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth under conditions | *Codes | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth required | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth under conditions | 2 Some codes may require prior authorization for both oncology and non-oncology diagnoses. For oncology diagnoses, refer to the Cancer Supportive Care section. For non-oncology diagnoses, submit prior | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Commercial | All | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare commercial plans Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth under conditions | site of care: outpatient | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 | |
| UnitedHealthcare | UnitedHealthcare Individual Exchange plans | All | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026 |
Q5122 appears in 19 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Donor Lymphocyte Infusion (0638) | not covered | Sep 29, 2026 | payer document |
| Aetna | Hematopoietic Colony-Stimulating Factors (CSFs) (0055) | covered if criteria are met | Jul 16, 2026 | payer document |
| Aetna | Lurbinectedin (Zepzelca) (0978) | listed, no stance | Mar 11, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (L.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (S.5.01.593) | listed, no stance | payer document | |
| Centene | Pegfilgrastim (Neulasta, Neulasta Onpro), Pegfilgrastim- unne (Armlupeg), Pegfilgrastim-pccg (Ennumo), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-pbbk (Fylnetra), Pegfilgrastim-apgf (Nyvepria), Eflapegrastim-xnst (Rolvedon), Efbemalenograstim alfa-vuxw (Ryzneuta), Pegfilgrastim-fpgk (Stimufend), Pegfilgrastim-cbqv (Udenyca, Udenyca Autoinjector, Udenyca Onbody), Pegfilgrastim-bmez (Ziextenzo) (CP.PHAR.296) | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Colony Stimulating Factors – Pegfilgrastim Products (IP0070) | covered if criteria are met | Mar 1, 2026 | payer document |
| Cigna | Colony Stimulating Factors – Pegfilgrastim Products (IP0070) | listed, no stance | Mar 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Oncology and Supportive Care Medications (RX502.061) oysk | Hycleta™ | listed, no stance | Jan 1, 2027 | payer document |
| Premera Blue Cross | Use of Granulocyte Colony-Stimulating Factors (G-CSF) (5.01.551) | listed, no stance | Sep 21, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (CS2026D0034AV) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (2026D0034AU) | listed, no stance | Aug 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (for Ohio Only) (CSOH2026D0034.K) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Maximum Dosage and Frequency (for Pennsylvania Only) (CSPA2026D0034AS) | listed, no stance | May 1, 2026 | payer document |
| UnitedHealthcare | Medicare Part B Step Therapy Programs (IAP.001.30) Non-Preferred | listed, no stance | Jul 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (CS2026D0061AL) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (2026D0061AE) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (for Indiana Only) (CSIND0061.14) | listed, no stance | Oct 1, 2025 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (for Ohio Only) (CSOH2025D0061.D) | listed, no stance | Nov 1, 2025 | payer document |
| Wellmark Blue Cross Blue Shield | Colony Stimulating Factors (05.02.41) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in CO, MS, VA, VT, WA.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.