Q5169 Inj, armlupeg, 0.5 mgInjection, pegfilgrastim-unne (armlupeg), biosimilar, 0.5 mg
Q5169 payment limit: $519.481 per 0.5 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026.
70748-0273-01 Armlupeg, Lupin Pharmaceuticals, Inc.: 12 billing units per package (1 SYRINGE in 1 CARTON / .6 mL in 1 SYRINGE)Status E: excluded from the PFS by regulation.
36 of 36 payer prior-auth lists that name Q5169 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of Illinois, Passport by Molina Healthcare (Kentucky), UnitedHealthcare, UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| 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) | Standard PA code list (most commercial plans) | AZ | prior auth required | site of care: site-of-service review | 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 required | site of care: site-of-service review | 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 | site of care: site-of-service review | 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 required | 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 | Apr 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Commercial | All | prior auth required | Apr 1, 2026 | Participating provider precertification list for Aetna® | |
| Aetna | Medicare Advantage | All | prior auth required | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jul 1, 2026 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jul 1, 2026 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jul 1, 2026 | Master Precertification List (For Health Care Providers) |
| 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 | Aug 1, 2026 | 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 | 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 | 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 | Step therapy | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (VA) | VA | prior auth required | 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 | New-to-market drug | 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 | 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 Healthcare of Illinois | Medicaid | IL | prior auth required | Jul 1, 2026 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| 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 |
| 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 Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | Michigan Medicaid, Healthy Michigan Plan, CSHCS | MI | prior auth required | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Michigan, Healthy Michigan Plan and Children’s Special Health Care Services Effective October 1, 2026 | |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth under conditions | site of care: outpatient | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
Q5169 appears in 6 coverage policies from Centene, 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 |
|---|---|---|---|---|
| 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 |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Oncology and Supportive Care Medications (RX502.061) Code | Generic | Brand | 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 | White Blood Cell Colony Stimulating Factors (2026D0061AE) | listed, no stance | Sep 1, 2026 | payer document |
| UnitedHealthcare | White Blood Cell Colony Stimulating Factors (CS2026D0061AL) | listed, no stance | Sep 1, 2026 | 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 MS.
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.