Policy # Policy Title Print View
VP-0007 Pemetrexed: Alimta®; Pemfexy™ (Intravenous)
VP-0008 Aloxi® (palonosetron) (Intravenous)
VP-0057 Trastuzumab: Herceptin®; Ogivri™; Kanjinti™; Trazimera™; Herzuma™; Ontruzant™ (Intravenous)
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-0100 Provenge® (sipuleucel-T) (Intravenous)
VP-0184 Gazyva (obinutuzumab) (Intravenous)
VP-0200 Sylvant™ (siltuximab) (Intravenous)
VP-0274 Imlygic™ (talimogene laherparepvec) Intralesional
VP-0283 Sustol® (granisetron extended-release) (Subcutaneous)
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-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-0482 Polivy™ (polatuzumab vedotin-piiq) (Intravenous)
VP-0531 Jelmyto™ (mitomycin) (Intra-pyelocalyceal)
VP-0547 Evomela® (melphalan) (Intravenous)
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-0647 Fyarro™ (sirolimus albumin-bound) (Intravenous)
VP-90014 Bevacizumab: Avastin®; Mvasi™; Zirabev™ (Intravenous)
VP-90109 Rituximab: Rituxan®, Truxima®, Ruxience® (Intravenous)