Noncovered
Services/Items
Abatacept
Azacitidine (Vidaza®)
Bendamustine hydrochloride (Treanda®, Bendaka™)
Bisphosphonates (Intravenous [IV]) & Monoclonal Antibodies for Treatment of Osteoporosis
Bortezomib (Velcade®)
Botulinum Toxins
Docetaxel
Taxotere
Doxorubicin, Liposomal (Doxil/Lipodox)
Etoposide (Etopophos®, Toposar®, Vepesid®, VP-16)
Erythropoiesis Stimulating Agents (ESA)
Fulvestrant (Faslodex®)
Hemophilia Clotting Factors
Infliximab (Remicade TM )
Irinotecan
Label & Off-label Coverage of Outpatient Drugs
& Biologicals
Leucovorin (Wellcovorin®)
Luteinizing Hormone-Releasing Hormone (LHRH) Analogs
Oxaliplatin
(Eloxatin®)
Omalizumab (Xolair®)
Paclitaxel (Taxol®)
Pegfilgrastim (Neulasta®)
Pemetrexed
Rituximab
(Rituxan ®)
Romiplostim (Nplate®)
Testosterone Pellets (Testopel®)
Topotecan Hydrochloride (Hycamtin®)
Trastuzumab (Herceptin®)
Vitamin B 12 Injections
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