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Draft Provider-Administered Oncology Drug Policies

Draft policies are listed below. If there are no policies listed, it means there are currently no policies in draft status.

 

Note: Coverage is subject to member's specific benefits. Group specific policies will supersede these policies when applicable. Please refer to member's benefit plan.

Comment on Draft Oncology Drug Policies

Participating providers are invited to submit for consideration scientific, evidence-based information, professional consensus opinions and other information supported by medical literature relevant to draft policies.

Comments are accepted for 45 days from the posting date listed on the draft policy.

Make sure your voice is heard by providing feedback directly to us:

Birmingham Service Center
Attn: Health Management — Medical Policy
P.O. Box 10527
Birmingham, AL 35202


Fax: 205-220-0878

Draft Policies

Policy # Policy Title Print View
VP-90001 Paclitaxel Albumin-Bound: Abraxane®; Paclitaxel Albumin-Bound Ψ
VP-90004 Adcetris® (brentuximab vedotin)
VP-90007 Pemetrexed: Alimta®; Pemfexy™; Pemrydi RTU®; Pemetrexed Ψ
VP-90014 Bevacizumab: Avastin®; Mvasi®; Zirabev®; Alymsys®; Vegzelma®; Avzivi®
VP-90038 Erbitux® (cetuximab) (Intravenous)
VP-90043 Fulvestrant: Faslodex®; Fulvestrant Ψ (Intramuscular)
VP-90055 Halaven® (eribulin)
VP-90057 Trastuzumab: Herceptin®; Ogivri®; Kanjinti®; Trazimera™; Herzuma®; Ontruzant®
VP-90092 Kadcyla® (ado-trastuzumab emtansine)
VP-90096 Perjeta® (pertuzumab)
VP-90130 Bendamustine: Treanda®; Bendeka®; Belrapzo®; Vivimusta™; Bendamustine Ψ
VP-90136 Vectibix® (panitumumab) (Intravenous)
VP-90137 Bortezomib Velcade®; Bortezomib§
VP-90148 Yervoy™ (ipilimumab) (Intravenous)
VP-90157 Kyprolis® (carfilzomib) (Intravenous)
VP-90161 Zaltrap® (ziv-aflibercept)
VP-90184 Gazyva (obinutuzumab) (Intravenous)
VP-90199 Cyramza® (ramucirumab)
VP-90209 Keytruda® (pembrolizumab)
VP-90225 Blincyto® (blinatumomab)
VP-90226 Opdivo® (nivolumab)
VP-90256 Onivyde® (irinotecan liposome injection)
VP-90257 Yondelis® (trabectedin)
VP-90266 Darzalex™ (daratumumab) (Intravenous)
VP-90268 Empliciti™ (elotuzumab) (Intravenous)
VP-90278 Tecentriq® (atezolizumab)
VP-90295 Bavencio® (avelumab) (Intravenous)
VP-90301 Imfinzi™ (durvalumab) (Intravenous)
VP-90322 Rituxan Hycela® (rituximab and hyaluronidase human)
VP-90398 Libtayo® (cemiplimab-rwlc) (Intravenous)
VP-90449 Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk)
VP-90528 Sarclisa® (isatuximab-irfc)
VP-90532 Trodelvy® (sacituzumab govitecan-hziy)
VP-90535 Darzalex Faspro® (daratumumab and hyaluronidase-fihj)
VP-90550 Zepzelca® (lurbinectedin)
VP-90553 Phesgo™ (pertuzumab, trastuzumab and hyaluronidase-zzxf)
VP-90559 Monjuvi® (tafasitamab-cxix)
VP-90583 Margenza® (margetuximab-cmkb)
VP-90599 Jemperli® (dostarlimab-gxly) (Intravenous)
VP-90600 Zynlonta® (loncastuximab tesirine-lpyl)
VP-90624 Tivdak® (tisotumab vedotin-tftv)
VP-90664 Opdualag™ (nivolumab/relatlimab-rmbw)
VP-90679 Pedmark® (sodium thiosulfate)
VP-90682 Tecvayli™ (teclistamab-cqyv)
VP-90683 Imjudo® (tremelimumab-actl) (Intravenous)
VP-90686 Elahere™ (mirvetuximab soravtansine-gynx)
VP-90692 Lunsumio™ (mosunetuzumab-axgb)
VP-90700 Zynyz™ (retifanlimab-dlwr) (Intravenous)
VP-90710 Epkinly™ (epcoritamab-bysp)
VP-90711 Columvi™ (glofitamab-gxbm)
VP-90722 Talvey™ (talquetamab-tgvs)
VP-90724 Elrexfio™ (elranatamab-bcmm)
VP-90735 Loqtorzi™ (toripalimab-tpzi) (Intravenous)
VP-90748 Amtagvi® (lifileucel)
VP-990209 Keytruda® (pembrolizumab)