Policy # Policy Title Print View
MP-650 Abraxane® (paclitaxel, protein-bound)
MP-651 Adcetris® (brentuximab vedotin)
MP-652 Alimta® (pemetrexed disodium)
MP-653 Arzerra® (ofatumumab) and Gazyva® (obinutuzumab)
MP-654 Avastin® (bevacizumab) -Oncologic Uses
MP-655 Cyramza® (ramucirumab)
MP-656 Erbitux® (cetuximab)
MP-657 Herceptin® (trastuzumab)
MP-658 Kadcyla® (ado-trastuzumab emtansine)
MP-659 Kyprolis® (Carfilzomib injection)
MP-660 Opdivo® (nivolumab)
MP-661 Perjeta® (pertuzumab)
MP-662 Provenge® (sipuleucel-T)
MP-663 Rituxan® (rituximab) – Oncologic Uses
MP-664 Vectibix® (panitumumab)
MP-665 Zaltrap® (ziv-aflibercept)
MP-666 Keytruda (pembrolizumab)
MP-667 Yervoy (ipilimumab)
MP-668 Tecentriq™ (Atezolizumab)
MP-669 Bendeka™ and Treanda® (bendamustine hydrochloride)
MP-670 Darzalex® (daratumumab)
MP-671 Empliciti™ (elotuzumab)
MP-672 Bavencio® (avelumab)
MP-673 Imfinzi (durvalumab)
MP-674 Blincyto® (blinatumomab)
MP-675 Kymriah™ (tisagenlecleucel)
MP-676 Yescarta™ (axicabtagene ciloleucel)
MP-677 Lartruvo™ (olaratumab)
MP-678 Besponsa (inotuzumab ozogamicin)
MP-679 Mylotarg® (gemtuzumab ozogamicin)
MP-680 Velcade® (bortezomib)
PH-100 Antiemetic Medical Policy Prior Authorization Program Summary (Akynzeo, Aloxi, Cinvanti, Emend IV, Palonosetron, Sustol, Varubi IV)
PH-106 Immune Globulin Policy Summary (Bivigam, Cuvitru, Flebogamma, GammaSTAN, Gammagard, Gammaked, Gammaplex, Gamunex, Hizentra, HyQvia, Octagam, Panzyga, Privigen)
PH-123 Colony Stimulating Factors Policy Summary (Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Udenyca, Zarxio)