Policy # Policy Title Print View
VP-0008 Aloxi® (palonosetron) (Intravenous)
VP-0036 Emend® (fosaprepitant dimeglumine) (Intravenous)
VP-0043 Faslodex® (fulvestrant) (Intramuscular)
VP-0071 Immune Globulins (immunoglobulin) (Intravenous)
VP-0072 Ixempra® (ixabepilone) (Intravenous)
VP-0089 Nplate™ (romiplostim) (Subcutaneous)
VP-0100 Provenge® (sipuleucel-T) (Intravenous)
VP-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ (Intravenous)
VP-0130 Bendamustine (Treanda®; Bendeka™; Belrapzo™) (Intravenous)
VP-0137 Velcade® (bortezomib) (Intravenous/Subcutaneous)
VP-0161 Zaltrap® (ziv-aflibercept) (Intravenous)
VP-0200 Sylvant™ (siltuximab) (Intravenous)
VP-0208 Arzerra® (ofatumumab) (Intravenous)
VP-0225 Blincyto® (blinatumomab) (Intravenous)
VP-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila™; Udenyca™; Ziextenzo™; Nyvepria™ (Subcutaneous)
VP-0235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio™); Tbo-Filgrastim (Granix®) (Subcutaneous/Intravenous)
VP-0237 Colony Stimulating Factors: Leukine® (sargramostim) (Subcutaneous/Intravenous)
VP-0257 Yondelis® (trabectedin) (Intravenous)
VP-0266 Darzalex™ (daratumumab) (Intravenous)
VP-0267 Portrazza™ (necitumumab) (Intravenous)
VP-0268 Empliciti™ (elotuzumab) (Intravenous)
VP-0274 Imlygic™ (talimogene laherparepvec) Intralesional
VP-0283 Sustol® (granisetron extended-release) (Subcutaneous)
VP-0301 Imfinzi™ (durvalumab) (Intravenous)
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-0322 Rituxan Hycela™ (rituximab and hyaluronidase human) (Subcutaneous)
VP-0333 Yescarta™ (axicabtagene ciloleucel) (Intravenous)
VP-0336 Cinvanti™ (aprepitant) (Intravenous)
VP-0351 Bortezomib* (Intravenous Only)
VP-0363 Akynzeo® (fosnetupitant/palonosetron) (Intravenous)
VP-0367 Elitek® (rasburicase) (Intravenous)
VP-0378 Poteligeo® (mogamulizumab-kpkc) (Intravenous)
VP-0393 Lumoxiti™ (moxetumomab pasudotox-tdfk) (Intravenous)
VP-0398 Libtayo® (cemiplimab-rwlc) (Intravenous)
VP-0426 Elzonris™ (tagraxofusp-erzs) (Intravenous)
VP-0449 Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) (Subcutaneous)
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-0531 Jelmyto™ (mitomycin) (Intra-pyelocalyceal)
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)
VP-0559 Monjuvi™ (tafasitamab-cxix) (Intravenous)
VP-0561 Blenrep® (belantamab mafodotin-blmf) (Intravenous)
VP-0581 Danyelza® (naxitamab-gqgk) (Intravenous)
VP-0583 Margenza™ (margetuximab-cmkb) (Intravenous)
VP-0590 Breyanzi® (lisocabtagene maraleucel) (Intravenous)
VP-0595 Pepaxto® (melphalan flufenamide) (Intravenous)
VP-0598 Abecma® (idecabtagene vicleucel) (Intravenous)
VP-0599 Jemperli® (dostarlimab-gxly) (Intravenous)
VP-0600 Zynlonta™ (loncastuximab tesirine-lpyl) (Intravenous)
VP-0607 Rybrevant™ (amivantamab-vmjw) (Intravenous)
VP-900014 Bevacizumab: Avastin®; Mvasi™; Zirabev™ (Intravenous)
VP-9057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti™; Trazimera™; Herzuma®; Ontruzant® (Intravenous)