Policy # Policy Title Print View
VP-0059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® (Subcutaneous)
VP-0071 Immune Globulins (immunoglobulin) (Intravenous)
VP-0072 Ixempra® (ixabepilone) (Intravenous)
VP-0089 Nplate™ (romiplostim) (Subcutaneous)
VP-0092 Kadcyla® (ado-trastuzumab emtansine) (Intravenous)
VP-0100 Provenge® (sipuleucel-T) (Intravenous)
VP-0130 Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ (Intravenous)
VP-0136 Vectibix® (panitumumab) (Intravenous)
VP-0137 Velcade® (bortezomib) (Intravenous/Subcutaneous)
VP-0157 Kyprolis® (carfilzomib) (Intravenous)
VP-0200 Sylvant™ (siltuximab) (Intravenous)
VP-0208 Arzerra® (ofatumumab) (Intravenous)
VP-0209 Keytruda® (pembrolizumab) (Intravenous)
VP-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit® (Subcutaneous/Intravenous)
VP-0267 Portrazza™ (necitumumab) (Intravenous)
VP-0268 Empliciti™ (elotuzumab) (Intravenous)
VP-0274 Imlygic™ (talimogene laherparepvec) Intralesional
VP-0314 Vyxeos® (daunorubicin and cytarabine – liposome) (Intravenous)
VP-0317 Besponsa (inotuzumab ozogamicin) (Intravenous)
VP-0319 Kymriah (tisagenlecleucel) (Intravenous)
VP-0320 Mylotarg (gemtuzumab ozogamicin) (Intravenous)
VP-0333 Yescarta™ (axicabtagene ciloleucel) (Intravenous)
VP-0367 Elitek® (rasburicase) (Intravenous)
VP-0378 Poteligeo® (mogamulizumab-kpkc) (Intravenous)
VP-0393 Lumoxiti™ (moxetumomab pasudotox-tdfk) (Intravenous)
VP-0449 Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) (Subcutaneous)
VP-0482 Polivy™ (polatuzumab vedotin-piiq) (Intravenous)
VP-0521 Padcev™ (enfortumab vedotin-ejfv) (Intravenous)
VP-0522 Enhertu® (fam-trastuzumab deruxtecan-nxki) (Intravenous)
VP-0528 Sarclisa® (isatuximab-irfc) (Intravenous)
VP-0531 Jelmyto™ (mitomycin) (Intra-pyelocalyceal)
VP-0547 Evomela® (melphalan) (Intravenous)
VP-0553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf) (Subcutaneous)
VP-0558 Tecartus™ (brexucabtagene autoleucel) (Intravenous)
VP-0559 Monjuvi™ (tafasitamab-cxix) (Intravenous)
VP-0561 Blenrep® (belantamab mafodotin-blmf) (Intravenous)
VP-0581 Danyelza® (naxitamab-gqgk) (Intravenous)
VP-0590 Breyanzi® (lisocabtagene maraleucel) (Intravenous)
VP-0598 Abecma® (idecabtagene vicleucel) (Intravenous)
VP-0607 Rybrevant™ (amivantamab-vmjw) (Intravenous)
VP-0647 Fyarro™ (sirolimus albumin-bound) (Intravenous)
VP-0658 Kimmtrak® (tebentafusp-tebn) (Intravenous)
VP-0663 Carvykti™ (ciltacabtagene autoleucel) (Intravenous)
VP-0664 Opdualag™ (nivolumab/relatlimab-rmbw) (Intravenous)
VP-0692 Lunsumio™ (mosunetuzumab-axgb) (Intravenous)
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys®; Vegzelma™ (Intravenous)
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant® (Intravenous)
VP-90109 Rituximab: Rituxan®, Truxima®, Ruxience™, Riabni™ (Intravenous)