Current Provider-Administered Oncology Drug Policies

Policy # Policy Title Print View
VP-0043 Faslodex® (fulvestrant) (Intramuscular)
VP-0057 Trastuzumab: Herceptin®; Ogivri™; Kanjinti™; Trazimera™; Herzuma™; Ontruzant™ (Intravenous)
VP-0089 Nplate™ (romiplostim) (Subcutaneous)
VP-0109 Rituximab: Rituxan®, Truxima®, Ruxience® (Intravenous)
VP-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca™; Ziextenzo™; Nyvepria™ (Subcutaneous)
VP-0336 Cinvanti™ (aprepitant) (Intravenous)
VP-0363 Akynzeo® (fosnetupitant/palonosetron) (Intravenous)
VP-0482 Polivy™ (polatuzumab vedotin-piiq) (Intravenous)
VP-0503 Reblozyl® (luspatercept-aamt) (Subcutaneous)
VP-0521 Padcev™ (enfortumab vedotin-ejfv) (Intravenous)
VP-0522 Enhertu® (fam-trastuzumab deruxtecan-nxki) (Intravenous)
VP-0528 Sarclisa® (isatuximab-irfc) (Intravenous)
VP-0532 Trodelvy™ (sacituzumab govitecan-hziy) (Intravenous)
VP-0535 Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Subcutaneous)
VP-0547 Evomela® (melphalan) (Intravenous)
VP-0550 Zepzelca™ (lurbinectedin) (Intravenous)
VP-0553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf) (Subcutaneous)
VP-0558 Tecartus™ (brexucabtagene autoleucel) (Intravenous)
Policy # Policy Title View
BA-650 Abraxane (paclitaxel, protein-bound)
BA-651 Adcetris® (brentuximab vedotin) - Blue Advantage
BA-652 Alimta (pemetrexed disodium)
BA-653 Arzerra (ofatumumab) and Gazyva (obinutuzumab) - Blue Advantage
BA-672 Bavencio® (avelumab)
BA-669 Bendeka and Treanda (bendamustine hydrochloride)
BA-678 Besponsa (inotuzumab ozogamicin)
BA-655 Cyramza (ramucirumab) - Blue Advantage
BA-670 Darzalex® (daratumumab)
BA-671 Empliciti (Elotuzumab)
BA-656 Erbitux (cetuximab)
BA-673 Imfinzi (durvalumab)
BA-658 Kadcyla® (ado-trastuzumab emtansine) - Blue Advantage
BA-659 Kyprolis (Carfilzomib injection) - Blue Advantage
BA-677 Lartruvo (olaratumab)
BA-679 Mylotarg (gemtuzumab ozogamicin)
BA-660 Opdivo® (nivolumab) - Blue Advantage
BA-661 Perjeta® (pertuzumab) - Blue Advantage
BA-668 Tecentriq™ (Atezolizumab) - Blue Advantage
BA-664 Vectibix® (panitumumab) - Blue Advantage
BA-667 Yervoy (ipilimumab) - Blue Advantage
BA-665 Zaltrap® (ziv-aflibercept) - Blue Advantage