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Evolent (formerly New Century Health) -
Medical Oncology Policies

Note: Starting Jan. 1, 2024, NCH Management Systems, Inc. d/b/a New Century Health became Evolent Specialty Services, Inc. (Evolent).

Welcome to the Evolent (formerly New Century Health) - Medical Oncology Policies page. Members follow the Medical Policies for the company underwriting or administering their benefit plan. See Frequently Asked Questions: ConnectiCare Oncology Drug Management to learn about the Medical Oncology Program and who these policies apply to.

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Policies are listed in alphabetical order.

A| B| C| D| E| F| G| H| I| J| K| L| M| N| O| P| Q| R| S| T| U| V| W| X| Y| Z
A
back to top		 Download (PDF)
Abraxane (nab paclitaxel) Download (PDF)
Adakveo (crizanlizumab) Download (PDF)
Adcetris (brentuximab vedotin) Download (PDF)
Adstiladrin Download (PDF)
Adzynma Download (PDF)
Alimta and Pemfexy Download (PDF)
Aliqopa (copanlisib) Download (PDF)
Amtagvi Download (PDF)
Anktiva Download (PDF)
Antiemetics Download (PDF)
Arranon (nelarabine) Download (PDF)
Arzerra Download (PDF)
Aphexda Download (PDF)
Asparlas (calaspargase pegol-mknl) Download (PDF)
Avastin (bevacizumab) and Biosimilars (Mvasi and Zirabev) Download (PDF)
Aucatzyl™ (obecabtagene autoleucel) Download (PDF)
B
back to top		 Download (PDF)
Bavencio Download (PDF)
Beleodaq (belinosat) Download (PDF)
Besponsa Download (PDF)
Besremi (ropeginterferon alfa-2b-nijft) Download (PDF)
Bizengri (zenocutuzumab-zbco) Download (PDF)
Blenrep (belantamab mafodotin-blmf) Download (PDF)
Blincyto (blinatumomab) Download (PDF)
Bone Modifying Agents (Aredia Zometa Xgeva Prolia) Download (PDF)
C
back to top		 Download (PDF)
Cablivi (caplacizumab-yhdp) Download (PDF)
Clolar (clofarabine) Download (PDF)
Criteria for evidence-based cancer therapies Download (PDF)
Columvi Download (PDF)
Cosela (trilaciclib) Download (PDF)
Cyramza (ramucirumab) Download (PDF)
D
back to top		 Download (PDF)
Danyelza (naxitamab-gqgk) Download (PDF)
Darzalex and Darzalex Faspro (daratumumab) Download (PDF)
Datroway (datopotamab deruxtecan-dlnk) Download (PDF)
Doxil or Lipodox Download (PDF)
E
back to top		 Download (PDF)
Elahere  Download (PDF)
Elrexfio™ (elranatamab-bcmm) Download (PDF)
Elzonris (tagraxofusp) Download (PDF)
Empaveli (pegcetacoplan) Download (PDF)
Empliciti Download (PDF)
Enhertu (fam-trastuzumab deruxtecan-nxki) Download (PDF)
Enjaymo (sutimlimab-jome) Download (PDF)
Erbitux (cetuximab) Download (PDF)
Erythropoiesis Stimulating Agents (Aranesp, Epogen, Procrit, Retacrit) Download (PDF)
F
back to top		 Download (PDF)
Faslodex Download (PDF)
Folotyn Download (PDF)
Fusilev Download (PDF)
Fyarro (sirolimus)
 Download (PDF)
G
back to top		 Download (PDF)
Gamifant (emapalumab-lzsg) Download (PDF)
Gazyva Download (PDF)
Generic Oncology Download (PDF)
H
back to top		 Download (PDF)
Halaven Download (PDF)
I
back to top		 Download (PDF)
Imdelltra Download (PDF)
Imfinzi Download (PDF)
Imjudo Download (PDF)
Imlygic Download (PDF)
Intravenous Immune Globulin (Aceniv, Panzyga, Bivigam, Carimune, Cuvitru, Gammagard, Gammaplex, Gamunex, Hiqvia, Gammaked, Octagam, Privigen) Download (PDF)
Iressa (gefitinib) Download (PDF)
Istodax Download (PDF)
Ixempra Download (PDF)
J
back to top		 Download (PDF)
Jelmyto (mitomycin for pyelocalyceal instillation) Download (PDF)
Jemperli (dostarlimab-gxly) Download (PDF)
Jevtana Download (PDF)
K
back to top		 Download (PDF)
Kadcyla Download (PDF)
Keytruda (pembrolizumab) Download (PDF)
Kimmtrak (tebentafusp-tebn) Download (PDF)
Kyprolis (carfilzomib) Download (PDF)
L
back to top		 Download (PDF)
LHRH (Agonists and antagonist) Download (PDF)
Libtayo (cemiplimab-rwlc) Download (PDF)
Loqtorzi Download (PDF)
Lumoxiti Download (PDF)
Lunsumio Download (PDF)
Lymphir Download (PDF)
M
back to top		 Download (PDF)
Margenza (margetuximab-cmkb) Download (PDF)
Marqibo (vincristine liposome) Download (PDF)
Monjuvi (tafasitamab-cxix) Download (PDF)
Mozobil (plerixafor) Download (PDF)
Myeloid Growth Factors (Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Nyvepria, Udenyca and Zarxio) Download (PDF)
Mylotarg Download (PDF)
N
back to top		 Download (PDF)
Nplate Download (PDF)
O
back to top		 Download (PDF)
Oncaspar (pegaspargase) Download (PDF)
Onivyde (irinotecan liposome) Download (PDF)
Opdivo and Opdivo Qvantiq (nivolumab IV/SC)  Download (PDF)
Opdualag (nivolumab and relatlimab-rmbw) Download (PDF)
P
back to top		 Download (PDF)
Padcev (enfortumab vedotin-ejfv) Download (PDF)
Pedmark (sodium thiosulfate) Download (PDF)
Pepaxto (melphalan flufenamide) Download (PDF)
Photofrin (porfimer) Download (PDF)
Piasky Download (PDF)
Polivy (polatuzumab vedotin) Download (PDF)
Poteligeo Download (PDF)
Provenge Download (PDF)
Q
back to top		 Download (PDF)
R
back to top		 Download (PDF)
Reblozyl (luspatercept-aamt) Download (PDF)
Rituximab Products (Riabni, Rituxan Hyclea, Ruxience, Truxima) Download (PDF)
Rybrevant (amivantamab-vmjw) Download (PDF)
Rylaze (asparaginase Erwinia chrysanthemi and recombinantrywn) Download (PDF)
Rytelo Download (PDF)
S
back to top		 Download (PDF)
Sarclisa (isatuximab-irfc) Download (PDF)
Soliris (eculizumab) Download (PDF)
Somatostatin Analog (Sandostatin and Somatuline) Download (PDF)
Sylvant (siltuximab) Download (PDF)
Synribo (omacetaxine) Download (PDF)
T
back to top		 Download (PDF)
Talvey (talquetamab-tgvs) Download (PDF)
Tecentriq Download (PDF)
Tecelra Download (PDF)
Tecvayli Download (PDF)
Tepadina (thiotepa) Download (PDF)
Tevimbra (tislelizumab-jsgr) Download (PDF)
Tivdak (tisotumab vedotin-tftv) Download (PDF)
Torisel (temsirolimus) Download (PDF)
Trastuzumab Products and Phesgo (pertuzumab trastuzumab and hyaluronidase-zzxf) Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, Trazimera Download (PDF)
Treanda_Bendeka_Belrapzo Download (PDF)
Trisenox (arsenic trioxide) Download (PDF)
Trodelvy (sacituzumab govitecan-hziy) Download (PDF)
U
back to top		 Download (PDF)
Ultomiris (ravulizumab) Download (PDF)
Unituxin (dinutuximab) Download (PDF)
V
back to top		 Download (PDF)
Valstar (valrubicin) Download (PDF)
Vectibix (panitumumab) Download (PDF)
Velcade (bortezomib) Download (PDF)
Vyloy™ (zolbetuximab-clzb) Download (PDF)
Vyxeos Download (PDF)
W
back to top		 Download (PDF)
X
back to top		 Download (PDF)
Y
back to top		 Download (PDF)
Yervoy (ipilimumab) Download (PDF)
Yondelis (trabectedin) Download (PDF)
Z
back to top		 Download (PDF)
Zaltrap (ziv-aflibercept) Download (PDF)
Zepzelca (lurbinectedin) Download (PDF)
Ziihera (zanidatamab-hrii) Download (PDF)
Zynlonta (loncastuzimab tesirine-lpyl) Download (PDF)
Zynyz (retifanlimab-dlwr) Download (PDF)
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your  plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.