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Current Provider-Administered Oncology Drug Policies

Policy # Policy Title Print View
VP-0001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-0004 Adcetris® (brentuximab vedotin)
VP-0007 Pemetrexed: Alimta®; Pemfexy™; Pemetrexed Ψ
VP-0014 Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys®; Vegzelma® *ONCOLOGY*
VP-0036 Fosaprepitant: Emend®; Fosaprepitant Ψ; Focinvez Ψ
VP-0038 Erbitux® (cetuximab)
VP-0043 Fulvestrant: Faslodex®; Fulvestrant Ψ
VP-0055 Halaven® (eribulin)
VP-0057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-0071 Immune Globulins (immunoglobulin) (Intravenous)
VP-0072 Ixempra® (ixabepilone) (Intravenous)
VP-0074 Cabazitaxel: Jevtana®; Cabazitaxel§
VP-008 Aloxi® (palonosetron) (Intravenous)
VP-0089 Nplate™ (romiplostim) (Subcutaneous)
VP-0092 Kadcyla® (ado-trastuzumab emtansine) (Intravenous)
VP-0096 Perjeta® (pertuzumab) (Intravenous)
VP-0100 Provenge® (sipuleucel-T) (Intravenous)
VP-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ (Intravenous)
VP-0130 Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ (Intravenous)
VP-0136 Vectibix® (panitumumab)
VP-0148 Yervoy™ (ipilimumab)
VP-0156 Synribo® (omacetaxine mepesuccinate)
VP-0157 Kyprolis® (carfilzomib)
VP-0161 Zaltrap® (ziv-aflibercept) (Intravenous)
VP-0166 Torisel® (temsirolimus)
VP-0184 Gazyva (obinutuzumab)
VP-0199 Cyramza™ (ramucirumab) (Intravenous)
VP-0200 Sylvant™ (siltuximab) (Intravenous)
VP-0205 Beleodaq® (belinostat)
VP-0209 Keytruda® (pembrolizumab)
VP-0216 Folotyn® (pralatrexate)
VP-0225 Blincyto® (blinatumomab) (Intravenous)
VP-0226 Opdivo® (nivolumab)
VP-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila®; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®; Stimufend® (Subcutaneous)
VP-0235 Colony Stimulating Factors: Filgrastim (Neupogen®); Filgrastim-aafi (Nivestym™); Filgrastim-sndz (Zarxio®); Filgrastim-ayow (Releuko®); Tbo-Filgrastim (Granix®) (Subcutaneous/Intravenous)
VP-0237 Colony Stimulating Factors: Leukine® (sargramostim) (Subcutaneous/Intravenous)
VP-0243 Epoetin alfa: Epogen®; Procrit®; Retacrit® (Subcutaneous/Intravenous)
VP-0256 Onivyde® (irinotecan liposome injection)
VP-0257 Yondelis® (trabectedin) (Intravenous)
VP-0266 Darzalex™ (daratumumab)
VP-0267 Portrazza™ (necitumumab) (Intravenous)
VP-0268 Empliciti™ (elotuzumab) (Intravenous)
VP-0274 Imlygic™ (talimogene laherparepvec) Intralesional
VP-0278 Tecentriq™ (atezolizumab)
VP-0283 Sustol® (granisetron extended-release) (Subcutaneous)
VP-0295 Bavencio® (avelumab)
VP-0301 Imfinzi™ (durvalumab)
VP-0317 Besponsa (inotuzumab ozogamicin) (Intravenous)
VP-0319 Kymriah (tisagenlecleucel) (Intravenous)
VP-0320 Mylotarg (gemtuzumab ozogamicin) (Intravenous)
VP-0321 Aliqopa® (copanlisib)
VP-0322 Rituxan Hycela™ (rituximab and hyaluronidase human) (Subcutaneous)
VP-0333 Yescarta™ (axicabtagene ciloleucel) (Intravenous)
VP-0336 Cinvanti™ (aprepitant)
VP-0363 Akynzeo® (fosnetupitant/palonosetron) (Intravenous)
VP-0378 Poteligeo® (mogamulizumab-kpkc)
VP-0393 Lumoxiti™ (moxetumomab pasudotox-tdfk) (Intravenous)
VP-0398 Libtayo® (cemiplimab-rwlc)
VP-0423 Infugem™ (gemcitabine)
VP-0425 Asparlas® (calaspargase pegol-mknl)
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-0581 Danyelza® (naxitamab-gqgk) (Intravenous)
VP-0583 Margenza™ (margetuximab-cmkb) (Intravenous)
VP-059 SCIG (immune globulin SQ): Hizentra®, Gammagard Liquid®, Gamunex®-C, Gammaked®, Hyqvia®, Cuvitru®, Cutaquig®, Xembify® (Subcutaneous)
VP-0590 Breyanzi® (lisocabtagene maraleucel) (Intravenous)
VP-0598 Abecma® (idecabtagene vicleucel) (Intravenous)
VP-0599 Jemperli® (dostarlimab-gxly)
VP-0600 Zynlonta™ (loncastuximab tesirine-lpyl) (Intravenous)
VP-0607 Rybrevant™ (amivantamab-vmjw) (Intravenous)
VP-0624 Tivdak™ (tisotumab vedotin-tftv) (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-0679 Pedmark® (sodium thiosulfate) (Intravenous)
VP-0682 Tecvayli™ (teclistamab-cqyv) (Subcutaneous)
VP-0683 Imjudo® (tremelimumab-actl) (Intravenous)
VP-0686 Elahere™ (mirvetuximab soravtansine-gynx) (Intravenous)
VP-0691 Adstiladrin® (nadofaragene firadenovec-vncg) (Intravesical)
VP-0692 Lunsumio™ (mosunetuzumab-axgb) (Intravenous)
VP-0700 Zynyz™ (retifanlimab-dlwr)
VP-0710 Epkinly™ (epcoritamab-bysp)
VP-0711 Columvi™ (glofitamab-gxbm)
VP-0722 Talvey™ (talquetamab-tgvs)
VP-0724 Elrexfio™ (elranatamab-bcmm)
VP-0735 Loqtorzi™ (toripalimab-tpzi)
VP-0741 Ryzneuta® (efbemalenograstim alfa-vuxw) (Subcutaneous)
VP-0748 Amtagvi® (lifileucel)
VP-314 Vyxeos® (daunorubicin and cytarabine – liposome) (Intravenous)
VP-367 Elitek® (rasburicase) (Intravenous)
VP-676 Rolvedon™ (eflapegrastim-xnst) (Subcutaneous)