Drugs & Biologicals

Select Alphabetically

Noncovered

Services/Items

A

Abatacept

Azacitidine (Vidaza®)

b

Bendamustine hydrochloride (Treanda®, Bendaka™)

Bisphosphonates (Intravenous [IV]) & Monoclonal Antibodies for Treatment of Osteoporosis

Bortezomib (Velcade®)

C

Carboplatin (Paraplatin®, Paraplatin-AQ®)

Cetuximab (Erbitux®)

d

Docetaxel

Taxotere

Doxorubicin, Liposomal (Doxil/Lipodox)

e

Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16)

Erythropoiesis Stimulating Agents (ESA)

f

 Fulvestrant (Faslodex®)

g

G-CSF ( Neupogen®, Granix™, Zarxio™)

Gemcitabine (Gemzar)

H

Hemophilia Clotting Factors

I

Infliximab (Remicade TM )

Irinotecan

J
K
L

Label & Off-label Coverage of Outpatient Drugs

& Biologicals

Leucovorin (Wellcovorin®)

Luteinizing Hormone-Releasing Hormone (LHRH) Analogs

M
n
O

Oxaliplatin

(Eloxatin®)

Omalizumab (Xolair®)

p

Paclitaxel (Taxol®)

 Pegfilgrastim (Neulasta®)

Pemetrexed

Q
r

Rituximab

(Rituxan ®)

Romiplostim (Nplate®)

S
T

Testosterone Pellets (Testopel®)

Topotecan Hydrochloride (Hycamtin®)

 Trastuzumab (Herceptin®)

U
V

Vitamin B 12 Injections

w
X
Y
Z

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