| Policy |
Policy Name |
Date Posted |
Date Removed |
| DMP0925-01 |
Daratumumab (Darzalex®) |
09/08/25 |
10/08/25 |
| DMP0925-02 |
Daratumumab and hyaluronidase-fihj (Darzalex Faspro®) |
09/08/25 |
10/08/25 |
| DMP0925-03 |
Ipilimumab (Yervoy®) |
09/08/25 |
10/08/25 |
| DMP0925-04 |
Pegaspargase (Oncaspar®) |
09/08/25 |
10/08/25 |
| DMP0925-05 |
Pemetrexed (Alimta®; Pemfexy™, Pemetrexed™, Pemrydi RTU, Axtle™) |
09/08/25 |
10/08/25 |
| DMP0925-06 |
Ramucirumab (Cyramza®) |
09/08/25 |
10/08/25 |
| DMP0925-07 |
Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin-C®, Zemaira®) |
09/08/25 |
10/08/25 |
| DMP0925-08 |
Avelumab (Bavencio®) |
09/08/25 |
10/08/25 |
| DMP0925-09 |
Bevacizumab Products |
09/08/25 |
10/08/25 |
| DMP0925-10 |
Efbemalenograstim alfa-vuxw (Ryzneuta®) |
09/08/25 |
10/08/25 |
| DMP0925-11 |
Nivolumab (Opdivo®) |
09/08/25 |
10/08/25 |
| DMP0925-12 |
Mepolizumab (Nucala®) |
09/08/25 |
10/08/25 |
| DMP0925-13 |
Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®) |
09/08/25 |
10/08/25 |
| DMP0925-14 |
Tocilizumab (Actemra®); Tocilizumab-anoh (Avtozma®); Tocilizumab-bavi (Tofidence™); Tocilizumab-aazg (Tyenne®), tocilizumab-aazg, tocilizumab-anoh |
09/08/25 |
10/08/25 |
| DMP0925-15 |
Ustekinumab Products |
09/08/25 |
10/08/25 |
| DMP0925-16 |
Vertebral Fracture Assessment with Densitometry or Biomechanical Computed Tomography |
09/15/25 |
10/15/25 |
| DMP0925-17 |
Cosibelimab-ipdl (Unloxcyt™) |
09/18/25 |
10/18/25 |
| DMP0925-18 |
Vutrisiran (Amvuttra™) |
09/18/25 |
10/18/25 |
| DMP0925-19 |
Allogeneic Processed Thymus Tissue-agdc (Rethymic®) |
09/18/25 |
10/18/25 |
| DMP0925-20 |
Nelarabine (Arranon®) |
09/18/25 |
10/18/25 |
| DMP0925-21 |
Eculizumab Products (Soliris®, Bkemv™ [Eculizumab-aeeb], and Epysqli® [Eculizumab-aagh]) |
09/23/25 |
10/23/25 |
| DMP0925-22 |
Facet Joint Neurotomy |
09/25/25 |
10/25/25 |
| DMP0925-23 |
Facet Joint Injections |
09/29/25 |
10/29/25 |
| DMP1025-01 |
Mitomycin (Zusduri™) |
10/01/25 |
11/01/25 |
| DMP1025-02 |
Avelumab (Bavencio®) |
10/02/25 |
11/02/25 |
| DMP1025-03 |
Axicabtagene Ciloleucel (Yescarta®) |
10/02/25 |
11/02/25 |
| DMP1025-04 |
Bendamustine Products (Treanda®, Belrapzo®, Bendeka®, Vivimusta™, Bendamustine) |
10/02/25 |
11/02/25 |
| DMP1025-05 |
Brentuximab Vedotin (Adcetris®) |
10/02/25 |
11/02/25 |
| DMP1025-06 |
Donanemab-azbt (KISUNLA™) |
10/02/25 |
11/02/25 |
| DMP1025-07 |
Emapalumab-lzsg (Gamifant™) |
10/02/25 |
11/02/25 |
| DMP1025-08 |
Enfortumab Vedotin-ejfv (Padcev®) |
10/02/25 |
11/02/25 |
| DMP1025-09 |
Epcoritamab-bysp (Epkinly™) |
10/02/25 |
11/02/25 |
| DMP1025-10 |
Glofitamab-gxbm (Columvi™) |
10/02/25 |
11/02/25 |
| DMP1025-11 |
Inclisiran (Leqvio®) |
10/02/25 |
11/02/25 |
| DMP1025-12 |
Inotersen (Tegsedi™) |
10/02/25 |
11/02/25 |
| DMP1025-13 |
Lisocabtagene Maraleucel (Breyanzi®) |
10/02/25 |
11/02/25 |
| DMP1025-14 |
Patisiran Lipid Complex (Onpattro®) |
10/02/25 |
11/02/25 |
| DMP1025-15 |
Pembrolizumab (Keytruda®) |
10/02/25 |
11/02/25 |
| DMP1025-16 |
Polatuzumab Vedotin-piiq (Polivy®) |
10/02/25 |
11/02/25 |
| DMP1025-17 |
Pralatrexate (Folotyn®); Pralatrexate |
10/02/25 |
11/02/25 |
| DMP1025-18 |
Rituximab Products (Rituxan®, Rituximab-abbs [Truxima®], Rituximab-arrx [Riabni™] and Rituximab-pvvr [Ruxience®]) |
10/02/25 |
11/02/25 |
| DMP1025-19 |
Temsirolimus (Torisel®) |
10/02/25 |
11/02/25 |
| DMP1025-20 |
Tisagenlecleucel (Kymriah®) |
10/02/25 |
11/02/25 |
