HCPCS Level II › Q codes Q5172 Inj, filkri, 1 mcgInjection, filgrastim-laha (filkri), biosimilar, 1 microgram
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medicare pricing for Q5172 Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for Q5172 19 of 19 payer prior-auth lists that name Q5172 require prior authorization or set conditions: Aetna, CarePlus Health Plans, Cigna, Humana.
Payer Plan State Prior auth Conditions Since Source Aetna Commercial All prior auth required May 1, 2026 Participating provider precertification list for Aetna® Aetna Medicare Advantage All prior auth required May 1, 2026 Participating provider precertification list for Aetna® Cigna ACA/IFP All prior auth required eviCore Medical Oncology Program for oncology diagnoses; Cigna for other indications; May be delegated to eviCore for some clients Oct 1, 2026 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required eviCore Medical Oncology Program for oncology diagnoses; Cigna for other indications; May be delegated to eviCore for some clients Oct 1, 2026 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required eviCore Medical Oncology Program for oncology diagnoses; Cigna for other indications; May be delegated to eviCore for some clients Oct 1, 2026 Master Precertification List (For Health Care Providers) 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:
Payer coverage policies that name Q5172 Q5172 appears in 2 coverage policies from Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross.
Payer Policy Role in policy Reviewed 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
Recent prior-auth changes Oct 14, 2026: PA added, Humana Oct 14, 2026: PA added, Humana Oct 14, 2026: PA added, Humana Oct 14, 2026: PA added, Humana Oct 14, 2026: PA added, Humana Oct 7, 2026: PA added, Humana Oct 1, 2026: PA added, Humana Jul 1, 2026: PA added, Humana Jul 1, 2026: PA added, CarePlus Health Plans May 1, 2026: PA added, Aetna 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.