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-0001 Abraxane® (paclitaxel protein-bound particles) (Intravenous)
VP-0004 Adcetris® (brentuximab vedotin) (Intravenous)
VP-0007 Pemetrexed: Alimta®; Pemfexy™ (Intravenous)
VP-0014 Bevacizumab: Avastin®; Mvasi®; Zirabev™; Alymsys® (Intravenous)
VP-0057 Trastuzumab: Herceptin®; Ogivri™; Kanjinti™; Trazimera™; Herzuma™; Ontruzant™ (Intravenous)
VP-0071 Immune Globulins (immunoglobulin) (Intravenous)
VP-0092 Kadcyla® (ado-trastuzumab emtansine) (Intravenous)
VP-0096 Perjeta® (pertuzumab) (Intravenous)
VP-0109 Rituximab: Rituxan®, Truxima®, Ruxience®, Riabni™ (Intravenous)
VP-0137 Velcade® (bortezomib) (Intravenous/Subcutaneous)
VP-0148 Yervoy™ (ipilimumab) (Intravenous)
VP-0157 Kyprolis® (carfilzomib) (Intravenous)
VP-0184 Gazyva (obinutuzumab) (Intravenous)
VP-0209 Keytruda® (pembrolizumab) (Intravenous)
VP-0226 Opdivo® (nivolumab) (Intravenous)
VP-0234 Colony Stimulating Factors – Pegfilgrastim: Neulasta®; Fulphila®; Udenyca®; Ziextenzo™; Nyvepria™; Fylnetra®; Stimufend® (Subcutaneous)
VP-0266 Darzalex™ (daratumumab) (Intravenous)
VP-0278 Tecentriq™ (atezolizumab) (Intravenous)
VP-0295 Bavencio® (avelumab) (Intravenous)
VP-0301 Imfinzi™ (durvalumab) (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-0393 Lumoxiti™ (moxetumomab pasudotox-tdfk) (Intravenous)
VP-0558 Tecartus™ (brexucabtagene autoleucel) (Intravenous)
VP-0559 Monjuvi™ (tafasitamab-cxix) (Intravenous)
VP-0590 Breyanzi® (lisocabtagene maraleucel) (Intravenous)
VP-0598 Abecma® (idecabtagene vicleucel) (Intravenous)
VP-0599 Jemperli® (dostarlimab-gxly) (Intravenous)
VP-0658 Kimmtrak® (tebentafusp-tebn) (Intravenous)
VP-0663 Carvykti™ (ciltacabtagene autoleucel) (Intravenous)
VP-0676 Rolvedon™ (eflapegrastim-xnst) (Subcutaneous)
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)