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Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
Policy Number: PH-91069
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx, and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
01-01-2025 |
05-01-2001 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Indications |
For the purposes of the Self-Administered Oncology Agents criteria, indications deemed appropriate are those within FDA labeling or supported in the allowed compendia (National Comprehensive Cancer Network [NCCN] Drugs & Biologics Compendium with a 1 or 2a recommended use, American Society of Health-System Pharmacists [AHFS], DrugDex level of evidence 1 or 2a). |
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Safety |
|
REFERENCES
Number |
Reference |
1 |
Voranigo prescribing information. Servier Pharmaceutical LLC. August 2024. |
2 |
Lazcluze prescribing information. Janssen Biotech, Inc. August 2024. |
3 |
Afinitor/Afinitor Disperz prescribing information. Novartis Pharmaceuticals Corporation. February 2022. |
4 |
Alecensa prescribing information. Genentech, Inc. April 2024. |
5 |
Alunbrig prescribing information. Takeda Pharmaceuticals America, Inc. February 2022. |
6 |
Ayvakit prescribing information. Blueprint Medicines Corp. May 2023. |
7 |
Balversa prescribing information. Janssen Products, LP. January 2024. |
8 |
BESREMi prescribing information. Pharmaessentia USA. April 2024. |
9 |
Bosulif tablets and capsules prescribing information. Pfizer Laboratories Div of Pfizer Inc. September 2023. |
10 |
Braftovi prescribing information. Array BioPharma Inc. October 2023. |
11 |
Brukinsa prescribing information. BeiGene, USA, Inc. June 2024. |
12 |
Cabometyx prescribing information. Exelixis, Inc. September 2023. |
13 |
Calquence tablet prescribing information. AstraZeneca Pharmaceuticals LP. June 2024. |
14 |
Caprelsa prescribing information. Genzyme Corporation. April 2024. |
15 |
Cometriq prescribing information. Exelixis, Inc. August 2023. |
16 |
Copiktra prescribing information. Secura Bio, Inc. February 2022. |
17 |
Cotellic prescribing information. Genentech, Inc. May 2023. |
18 |
Daurismo prescribing information. Pfizer Laboratories Div Pfizer Inc. March 2023. |
19 |
Erivedge prescribing information. Genentech, Inc. March 2023. |
20 |
Erleada prescribing information. Janssen Products, LP. July 2024. |
21 |
Reference no longer used |
22 |
Reference no longer used |
23 |
Fotivda prescribing information. Aveo Pharmaceuticals, Inc. March 2021. |
24 |
Gavreto prescribing information. Genentech Inc. March 2024. |
25 |
Gilotrif prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. April 2022. |
26 |
Gleevec prescribing information. Novartis Pharmaceuticals Corporation. March 2024. |
27 |
Hycamtin prescribing Information. Novartis Pharmaceuticals Corporation. September 2018. |
28 |
Ibrance prescribing information. Pfizer Inc. September 2023. |
29 |
Iclusig prescribing information. Takeda Pharmaceuticals America, Inc. March 2024. |
30 |
Idhifa prescribing information. Celgene Corporation. December 2023. |
31 |
Imbruvica prescribing information. Pharmacyclics LLC. May 2024. |
32 |
Inlyta prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2022. |
33 |
Inqovi prescribing information. Taiho Pharmaceutical Co., LTD. March 2022. |
34 |
Inrebic prescribing information. Celgene Corporation. May 2023. |
35 |
Iressa prescribing information. AstraZeneca Pharmaceuticals LP. February 2023. |
36 |
Jakafi prescribing information. Incyte Corporation. January 2023. |
37 |
Kisqali Femara Pack prescribing information. Novartis Pharmaceuticals Corporation. August 2023. |
38 |
Kisqali prescribing information. Novartis Pharmaceuticals Corporation. August 2023. |
39 |
Koselugo prescribing information. AstraZeneca Pharmaceuticals LP. January 2024. |
40 |
Lenvima prescribing information. Eisai Inc. June 2024. |
41 |
Lonsurf prescribing information. Taiho Pharmaceutical Co., Ltd. August 2023. |
42 |
Lorbrena prescribing information. Pfizer Laboratories Div Pfizer Inc. April 2023. |
43 |
Lumakras prescribing information. Amgen Inc. June 2024. |
44 |
Lynparza prescribing information. AstraZeneca Pharmaceuticals LP. November 2023. |
45 |
Lysodren prescribing information. HRA Pharma Rare Diseases. January 2024. |
46 |
Matulane prescribing information. Leadiant Biosciences. November 2023. |
47 |
Mekinist prescribing information. Novartis Pharmaceuticals Corporation. March 2024. |
48 |
Mektovi prescribing information. Array BioPharma Inc. October 2023. |
49 |
Nerlynx prescribing information. Puma Biotechnology, Inc. March 2022. |
50 |
Nexavar prescribing information. Bayer HealthCare Pharmaceuticals Inc. August 2022. |
51 |
Ninlaro prescribing information. Takeda Pharmaceuticals America, Inc. July 2024. |
52 |
Nubeqa prescribing information. Bayer HealthCare Pharmaceuticals Inc. October 2023. |
53 |
Odomzo prescribing information. Sun Pharmaceutical Industries, Inc. August 2023. |
54 |
Onureg prescribing information. Celgene Corporation. October 2022. |
55 |
Orgovyx prescribing information. Sumitomo Pharma America, Inc. August 2023. |
56 |
Pemazyre prescribing information. Incyte Corporation. June 2023. |
57 |
Piqray prescribing information. Novartis Pharmaceuticals Corp. January 2024. |
58 |
Pomalyst prescribing information. Celgene Corporation. March 2023. |
59 |
Qinlock prescribing information. Deciphera Pharmaceuticals, LLC. October 2023. |
60 |
Retevmo prescribing information. Eli Lilly and Company. May 2024. |
61 |
Revlimid prescribing information. Celgene Corporation. March 2023. |
62 |
Rozlytrek prescribing information. Genentech USA, Inc. January 2024. |
63 |
Rubraca prescribing information. Clovis Oncology, Inc. December 2022. |
64 |
Rydapt prescribing information. Novartis Pharmaceuticals Corporation. May 2023. |
65 |
Scemblix prescribing information. Novartis Pharmaceuticals Corporation. April 2024. |
66 |
Sprycel prescribing information. E.R. Squibb & Sons, L.L.C. February 2023. |
67 |
Stivarga prescribing information. Bayer Healthcare Pharmaceuticals Inc. December 2020. |
68 |
Sutent prescribing information. Pfizer Laboratories Div Pfizer Inc. August 2021. |
69 |
Tabrecta prescribing information. Novartis Pharmaceuticals Corp. March 2024. |
70 |
Tafinlar prescribing information. Novartis Pharmaceuticals Corporation. March 2024. |
71 |
Tagrisso prescribing information. AstraZeneca Pharmaceuticals LP. April 2024. |
72 |
Talzenna prescribing information. Pfizer Laboratories Div Pfizer Inc. March 2024. |
73 |
Tarceva prescribing information. Genentech inc. October 2016. |
74 |
Targretin capsule prescribing information. Bausch Health US, LLC. April 2020. |
75 |
Targretin gel prescribing information. Bausch Health US, LLC. February 2020. |
76 |
Tasigna prescribing information. Novartis Pharmaceuticals Corporation. February 2024. |
77 |
Tazverik prescribing information. Epizyme Inc. December 2023. |
78 |
Temodar prescribing Information. Merck Sharp & Dohme LLC. September 2023. |
79 |
Tepmetko prescribing information. EMD Serono, Inc. February 2024. |
80 |
Thalomid prescribing information. Celgene Corporation. March 2023. |
81 |
Tibsovo prescribing information. Servier Pharmaceuticals LLC, Inc. October 2023. |
82 |
Tretinoin prescribing information. Glenmark Pharmaceuticals, Inc, USA. April 2023. |
83 |
Truseltiq prescribing information. QED Therapeutics Inc. May 2021. |
84 |
Tukysa prescribing information. Seagen Inc. January 2023. |
85 |
Turalio prescribing information. Daiichi Sankyo, Inc. November 2023. |
86 |
Tykerb prescribing information. Novartis Pharmaceuticals Corporation. March 2022. |
87 |
Reference is no longer used |
88 |
Venclexta prescribing information. AbbVie Inc. July 2024. |
89 |
Verzenio prescribing information. Eli Lilly and Company. January 2024. |
90 |
Vitrakvi prescribing information. Bayer HealthCare Pharmaceuticals Inc. November 2023. |
91 |
Vizimpro prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2020. |
92 |
Votrient prescribing information. Novartis Pharmaceuticals Corporation. January 2024. |
93 |
Welireg prescribing information. Merck Sharp & Dohme LLC. December 2023. |
94 |
Xalkori prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2023. |
95 |
Xeloda prescribing information. Genentech, Inc. April 2023. |
96 |
Xospata prescribing information. Astellas Pharma US, Inc. January 2022. |
97 |
Xpovio prescribing information. Karyopharm Therapeutics Inc. July 2022. |
98 |
Xtandi prescribing information. Astellas Pharma US, Inc. November 2023. |
99 |
Yonsa prescribing information. Sun Pharmaceuticals Industries, Inc. March 2022. |
100 |
Zejula capsule prescribing information. GlaxoSmithKline. May 2024. |
101 |
Zelboraf prescribing information. Genentech, Inc. May 2020. |
102 |
Zolinza prescribing information. Merck Sharp & Dohme LLC. July 2022. |
103 |
Zydelig prescribing information. Gilead Sciences, Inc. February 2022. |
104 |
Zykadia prescribing information. Novartis Pharmaceuticals Corporation. October 2021. |
105 |
Zytiga prescribing information. Janssen Biotech, Inc. August 2021. |
106 |
Vonjo prescribing information. CTI Biopharma Corp. August 2023. |
107 |
Lytgobi prescribing information. Taiho Pharmaceutical Co., LTD. April 2024. |
108 |
Rezlidhia prescribing information. Rigel Pharmaceuticals, Inc. December 2022. |
109 |
Krazati prescribing information. Mirati Therapeutics, Inc. June 2024. |
110 |
Jaypirca prescribing information. Eli Lilly and Company. June 2024. |
111 |
Orserdu prescribing information. Stemline Therapeutics, Inc. November 2023. |
112 |
Zejula tablet prescribing information. GlaxoSmithKline. May 2024. |
113 |
Vanflyta prescribing information. Daiichi Sankyo Inc. June 2024. |
114 |
Akeega prescribing information. Janssen Biotech, Inc. August 2023. |
115 |
Ojjaara prescribing information. GlaxoSmithKline LLC. September 2023. |
116 |
Fruzaqla prescribing information. Takeda Pharmaceuticals U.S.A., Inc. November 2023 |
117 |
Truqap prescribing information. AstraZeneca Pharmaceuticals LP. November 2023. |
118 |
Augtyro prescribing information. E.R Squibb & Sons, LLC. June 2024. |
119 |
Ogsiveo prescribing information. SpringWorks Therapeutics, Inc. November 2023. |
120 |
Iwilfin prescribing information.US Worldmeds (USWM), LCC. December 2023. |
121 |
Ojemda prescribing information. Day One Biopharmaceuticals, Inc. June 2024. |
POLICY AGENT SUMMARY PRIOR AUTHORIZATION
Target Brand Agent(s) |
Target Generic Agent(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
||||||
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Yonsa |
abiraterone acetate micronized tab |
125 MG |
M ; N ; O ; Y |
N |
|
|
Zytiga |
abiraterone acetate tab |
250 MG ; 500 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Calquence |
acalabrutinib cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Calquence |
acalabrutinib cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Calquence |
acalabrutinib maleate tab |
100 MG |
M ; N ; O ; Y |
N |
|
|
Krazati |
adagrasib tab |
200 MG |
M ; N ; O ; Y |
N |
|
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
M ; N ; O ; Y |
N |
|
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
M ; N ; O ; Y |
N |
|
|
Alecensa |
alectinib hcl cap |
150 MG |
M ; N ; O ; Y |
N |
|
|
Alecensa |
alectinib hcl cap |
150 MG |
M ; N ; O ; Y |
N |
|
|
Piqray 200mg daily dose ; Piqray 250mg daily dose ; Piqray 300mg daily dose |
alpelisib tab pack ; alpelisib tab therapy pack |
150 MG ; 200 & 50 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Erleada |
apalutamide tab |
240 MG ; 60 MG |
M ; N ; O ; Y |
N |
|
|
Scemblix |
asciminib hcl tab |
100 MG ; 20 MG ; 40 MG |
M ; N ; O ; Y |
N |
|
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Inlyta |
axitinib tab |
1 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
Inlyta |
axitinib tab |
1 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
Onureg |
azacitidine tab |
200 MG ; 300 MG |
M ; N ; O ; Y |
N |
|
|
Welireg |
belzutifan tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
Targretin |
bexarotene cap |
75 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Targretin |
Bexarotene Gel 1% |
1 % |
M ; N ; O ; Y |
O ; Y |
|
|
Mektovi |
binimetinib tab |
15 MG |
M ; N ; O ; Y |
N |
|
|
Bosulif |
bosutinib cap ; bosutinib tab |
100 MG ; 400 MG ; 50 MG ; 500 MG |
M ; N ; O ; Y |
N |
|
|
Alunbrig |
brigatinib tab |
180 MG ; 30 MG ; 90 MG |
M ; N ; O ; Y |
N |
|
|
Alunbrig |
brigatinib tab ; brigatinib tab initiation therapy pack |
180 MG ; 30 MG ; 90 & 180 MG ; 90 MG |
M ; N ; O ; Y |
N |
|
|
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
M ; N ; O ; Y |
N |
|
|
Cometriq |
cabozantinib s-mal cap ; cabozantinib s-malate cap |
20 MG ; 3 x 20 MG & 80 MG ; 80 & 20 MG |
M ; N ; O ; Y |
N |
|
|
Cabometyx |
cabozantinib s-malate tab |
20 MG ; 40 MG ; 60 MG |
M ; N ; O ; Y |
N |
|
|
Xeloda |
capecitabine tab |
150 MG ; 500 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Truqap |
capivasertib tab |
160 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Truqap |
capivasertib tab therapy pack |
160 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Zykadia |
ceritinib tab |
150 MG |
M ; N ; O ; Y |
N |
|
|
Zykadia |
ceritinib tab |
150 MG |
M ; N ; O ; Y |
N |
|
|
Cotellic |
cobimetinib fumarate tab |
20 MG |
M ; N ; O ; Y |
N |
|
|
Xalkori |
crizotinib cap ; crizotinib cap sprinkle |
150 MG ; 20 MG ; 200 MG ; 250 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
M ; N ; O ; Y |
N |
|
|
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
M ; N ; O ; Y |
N |
|
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
M ; N ; O ; Y |
N |
|
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
M ; N ; O ; Y |
N |
|
|
Nubeqa |
darolutamide tab |
300 MG |
M ; N ; O ; Y |
N |
|
|
Sprycel |
dasatinib tab |
100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
M ; N ; O ; Y |
N |
|
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
M ; N ; O ; Y |
N |
|
|
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Iwilfin |
eflornithine hcl tab |
192 MG |
M ; N ; O ; Y |
N |
|
|
Orserdu |
elacestrant hydrochloride tab |
345 MG ; 86 MG |
M ; N ; O ; Y |
N |
|
|
Idhifa |
enasidenib mesylate tab |
100 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Braftovi |
encorafenib cap |
75 MG |
M ; N ; O ; Y |
N |
|
|
Rozlytrek |
entrectinib cap |
100 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Rozlytrek |
entrectinib pellet pack |
50 MG |
M ; N ; O ; Y |
N |
|
|
Xtandi |
enzalutamide cap |
40 MG |
M ; N ; O ; Y |
N |
|
|
Xtandi |
enzalutamide tab |
40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Balversa |
erdafitinib tab |
3 MG ; 4 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Afinitor ; Torpenz |
everolimus tab |
10 ; 10 MG ; 2.5 ; 2.5 MG ; 5 ; 5 MG ; 7.5 ; 7.5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Afinitor ; Torpenz |
Everolimus Tab 10 MG |
10 ; 10 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Afinitor ; Torpenz |
Everolimus Tab 5 MG |
5 ; 5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Afinitor disperz |
everolimus tab for oral susp |
2 MG ; 3 MG ; 5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Inrebic |
fedratinib hcl cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Fruzaqla |
fruquintinib cap |
1 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
Lytgobi |
futibatinib tab therapy pack |
4 MG |
M ; N ; O ; Y |
N |
|
|
Iressa |
gefitinib tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Iressa |
gefitinib tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Xospata |
gilteritinib fumarate tablet |
40 MG |
M ; N ; O ; Y |
N |
|
|
Xospata |
gilteritinib fumarate tablet |
40 MG |
M ; N ; O ; Y |
N |
|
|
Daurismo |
glasdegib maleate tab |
100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Imbruvica |
ibrutinib cap ; ibrutinib oral susp ; ibrutinib tab |
140 MG ; 280 MG ; 420 MG ; 560 MG ; 70 MG ; 70 MG/ML |
M ; N ; O ; Y |
N |
|
|
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
M ; N ; O ; Y |
N |
|
|
Gleevec |
imatinib mesylate tab |
100 MG ; 400 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Truseltiq |
infigratinib phos cap pack ; infigratinib phos cap ther pack |
100 & 25 MG ; 100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Tibsovo |
ivosidenib tab |
250 MG |
M ; N ; O ; Y |
N |
|
|
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
M ; N ; O ; Y |
N |
|
|
Tykerb |
lapatinib ditosylate tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Tykerb |
lapatinib ditosylate tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Vitrakvi |
larotrectinib sulfate cap |
100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Vitrakvi |
larotrectinib sulfate oral soln |
20 MG/ML |
M ; N ; O ; Y |
N |
|
|
Lazcluze |
lazertinib mesylate tab |
240 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Revlimid |
lenalidomide cap ; lenalidomide caps |
10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 25 MG ; 5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Lenvima 10 mg daily dose ; Lenvima 12mg daily dose ; Lenvima 14 mg daily dose ; Lenvima 18 mg daily dose ; Lenvima 20 mg daily dose ; Lenvima 24 mg daily dose ; Lenvima 4 mg daily dose ; Lenvima 8 mg daily dose |
lenvatinib cap ther pack ; lenvatinib cap therapy pack |
10 & 4 MG ; 10 MG ; 10 MG & 2 x 4 MG ; 2 x 10 MG & 4 MG ; 4 MG |
M ; N ; O ; Y |
N |
|
|
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Rydapt |
midostaurin cap |
25 MG |
M ; N ; O ; Y |
N |
|
|
Lysodren |
mitotane tab |
500 MG |
M ; N ; O ; Y |
N |
|
|
Ojjaara |
momelotinib dihydrochloride tab |
100 MG ; 150 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Nerlynx |
neratinib maleate tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
Nerlynx |
neratinib maleate tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Zejula |
niraparib tosylate cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Zejula |
niraparib tosylate tab |
100 MG ; 200 MG ; 300 MG |
M ; N ; O ; Y |
N |
|
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG ; 50-500 MG |
M ; N ; O ; Y |
N |
|
|
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG ; 150 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Lynparza |
olaparib tab |
100 MG ; 150 MG |
M ; N ; O ; Y |
N |
|
|
Rezlidhia |
olutasidenib cap |
150 MG |
M ; N ; O ; Y |
N |
|
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Vonjo |
pacritinib citrate cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Ibrance |
palbociclib cap |
100 MG ; 125 MG ; 75 MG |
M ; N ; O ; Y |
N |
|
|
Ibrance |
palbociclib cap ; palbociclib tab |
100 MG ; 125 MG ; 75 MG |
M ; N ; O ; Y |
N |
|
|
Votrient |
pazopanib hcl tab |
200 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Votrient |
pazopanib hcl tab |
200 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Pemazyre |
pemigatinib tab |
13.5 MG ; 4.5 MG ; 9 MG |
M ; N ; O ; Y |
N |
|
|
Turalio |
pexidartinib hcl cap |
125 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Turalio |
pexidartinib hcl cap |
125 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
Jaypirca |
pirtobrutinib tab |
100 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
M ; N ; O ; Y |
N |
|
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
M ; N ; O ; Y |
N |
|
|
Iclusig |
ponatinib hcl tab |
10 MG ; 15 MG ; 30 MG ; 45 MG |
M ; N ; O ; Y |
N |
|
|
Gavreto |
pralsetinib cap |
100 MG |
M ; N ; O ; Y |
M ; N |
|
|
Gavreto |
pralsetinib cap |
100 MG |
M ; N ; O ; Y |
M ; N |
|
|
Matulane |
procarbazine hcl cap |
50 MG |
M ; N ; O ; Y |
N |
|
|
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG ; 26.5 MG |
M ; N ; O ; Y |
N |
|
|
Stivarga |
regorafenib tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
Orgovyx |
relugolix tab |
120 MG |
M ; N ; O ; Y |
N |
|
|
Augtyro |
repotrectinib cap |
40 MG |
M ; N ; O ; Y |
N |
|
|
Kisqali femara 200 dose ; Kisqali femara 400 dose ; Kisqali femara 600 dose |
ribociclib |
200 & 2.5 MG |
M ; N ; O ; Y |
N |
|
|
Kisqali |
ribociclib succinate tab pack |
200 MG |
M ; N ; O ; Y |
N |
|
|
Qinlock |
ripretinib tab |
50 MG |
M ; N ; O ; Y |
N |
|
|
Qinlock |
ripretinib tab |
50 MG |
M ; N ; O ; Y |
N |
|
|
Besremi |
ropeginterferon alfa- |
500 MCG/ML |
M ; N ; O ; Y |
N |
|
|
Rubraca |
rucaparib camsylate tab |
200 MG ; 250 MG ; 300 MG |
M ; N ; O ; Y |
N |
|
|
Jakafi |
ruxolitinib phosphate tab |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
Xpovio ; Xpovio 60 mg twice weekly ; Xpovio 80 mg twice weekly |
selinexor tab therapy pack |
20 MG ; 40 MG ; 50 MG ; 60 MG |
M ; N ; O ; Y |
N |
|
|
Retevmo |
selpercatinib cap |
40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Retevmo |
selpercatinib cap ; selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Retevmo |
selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
Koselugo |
selumetinib sulfate cap |
10 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
Odomzo |
sonidegib phosphate cap |
200 MG |
M ; N ; O ; Y |
N |
|
|
Nexavar |
sorafenib tosylate tab |
200 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Lumakras |
sotorasib tab |
120 MG ; 320 MG |
M ; N ; O ; Y |
N |
|
|
Sutent |
sunitinib malate cap |
12.5 MG ; 25 MG ; 37.5 MG ; 50 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Talzenna |
talazoparib tosylate cap |
0.1 MG ; 0.25 MG ; 0.35 MG ; 0.5 MG ; 0.75 MG ; 1 MG |
M ; N ; O ; Y |
N |
|
|
Tazverik |
tazemetostat hbr tab |
200 MG |
M ; N ; O ; Y |
N |
|
|
Temodar |
temozolomide cap |
100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
Thalomid |
thalidomide cap |
100 MG ; 150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Fotivda |
tivozanib hcl cap |
0.89 MG ; 1.34 MG |
M ; N ; O ; Y |
N |
|
|
Hycamtin |
topotecan hcl cap |
0.25 MG ; 1 MG |
M ; N ; O ; Y |
N |
|
|
Ojemda |
tovorafenib for oral susp ; tovorafenib tab |
100 MG ; 25 MG/ML |
M ; N ; O ; Y |
N |
|
|
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
M ; N ; O ; Y |
N |
|
|
Mekinist |
trametinib dimethyl sulfoxide tab |
0.5 MG ; 2 MG |
M ; N ; O ; Y |
N |
|
|
|
tretinoin cap |
10 MG |
M ; N ; O ; Y |
Y |
|
|
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG ; 20-8.19 MG |
M ; N ; O ; Y |
N |
|
|
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
M ; N ; O ; Y |
N |
|
|
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
M ; N ; O ; Y |
N |
|
|
Zelboraf |
vemurafenib tab |
240 MG |
M ; N ; O ; Y |
N |
|
|
Venclexta |
venetoclax tab |
10 MG ; 100 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
Venclexta starting pack |
venetoclax tab therapy starter pack |
10 & 50 & 100 MG |
M ; N ; O ; Y |
N |
|
|
Erivedge |
vismodegib cap |
150 MG |
M ; N ; O ; Y |
N |
|
|
Voranigo |
vorasidenib tab |
10 MG ; 40 MG |
M ; N ; O ; Y |
N |
|
|
Zolinza |
vorinostat cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
Brukinsa |
zanubrutinib cap |
80 MG |
M ; N ; O ; Y |
N |
|
|
Brukinsa |
zanubrutinib cap |
80 MG |
M ; N ; O ; Y |
N |
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
|
|
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Erlotinib HCl Tab |
25 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Afinitor ; Torpenz |
everolimus tab |
10 ; 10 MG ; 2.5 ; 2.5 MG ; 5 ; 5 MG ; 7.5 ; 7.5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Afinitor disperz |
Everolimus Tab for Oral Susp 2 MG |
2 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Afinitor disperz |
Everolimus Tab for Oral Susp 3 MG |
3 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Afinitor disperz |
Everolimus Tab for Oral Susp 5 MG |
5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
50-500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Alecensa |
alectinib hcl cap |
150 MG |
240 |
Capsules |
30 |
DAYS |
|
|
|
Alunbrig |
Brigatinib Tab |
30 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Alunbrig |
Brigatinib Tab |
90 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Alunbrig |
Brigatinib Tab |
180 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
30 |
Tablets |
180 |
DAYS |
|
|
|
Augtyro |
repotrectinib cap |
40 MG |
240 |
Capsules |
30 |
DAYS |
|
|
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Balversa |
Erdafitinib Tab 3 MG |
3 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Balversa |
Erdafitinib Tab 4 MG |
4 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Balversa |
Erdafitinib Tab 5 MG |
5 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Besremi |
Ropeginterferon alfa- |
500 MCG/ML |
2 |
Syringes |
28 |
DAYS |
|
|
|
Bosulif |
bosutinib cap |
50 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Bosulif |
bosutinib cap |
100 MG |
150 |
Capsules |
30 |
DAYS |
|
|
|
Bosulif |
Bosutinib Tab |
100 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Bosulif |
bosutinib tab |
100 MG ; 400 MG ; 500 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Braftovi |
encorafenib cap |
75 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
Brukinsa |
Zanubrutinib Cap |
80 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Cabometyx |
Cabozantinib S-Malate Tab |
20 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Cabometyx |
Cabozantinib S-Malate Tab |
40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Cabometyx |
Cabozantinib S-Malate Tab |
60 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Calquence |
acalabrutinib cap |
100 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Calquence |
acalabrutinib maleate tab |
100 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Caprelsa |
Vandetanib Tab |
100 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Caprelsa |
Vandetanib Tab |
300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Cometriq |
Cabozantinib S-Mal Cap |
80 & 20 MG |
1 |
Carton |
28 |
DAYS |
|
|
|
Cometriq |
Cabozantinib S-Mal Cap |
3 x 20 MG & 80 MG |
1 |
Carton |
28 |
DAYS |
|
|
|
Cometriq |
Cabozantinib S-Malate Cap |
20 MG |
1 |
Carton |
28 |
DAYS |
|
|
|
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
56 |
Capsules |
28 |
DAYS |
|
|
|
Cotellic |
cobimetinib fumarate tab |
20 MG |
63 |
Tablets |
28 |
DAYS |
|
|
|
Daurismo |
Glasdegib Maleate Tab 100 MG (Base Equivalent) |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Daurismo |
Glasdegib Maleate Tab 25 MG (Base Equivalent) |
25 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Erivedge |
Vismodegib Cap 150 MG |
150 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Erleada |
apalutamide tab |
240 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Erleada |
Apalutamide Tab 60 MG |
60 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Fotivda |
Tivozanib HCl Cap |
0.89 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Fotivda |
Tivozanib HCl Cap |
1.34 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Fruzaqla |
fruquintinib cap |
1 MG |
84 |
Capsules |
28 |
DAYS |
|
|
|
Fruzaqla |
fruquintinib cap |
5 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Gavreto |
pralsetinib cap |
100 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Gleevec |
Imatinib Mesylate Tab |
100 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Gleevec |
Imatinib Mesylate Tab |
400 MG |
60 |
|
30 |
DAYS |
|
|
|
Ibrance |
palbociclib cap ; palbociclib tab |
100 MG ; 125 MG ; 75 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Iclusig |
Ponatinib HCl Tab |
10 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Iclusig |
Ponatinib HCl Tab |
15 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Iclusig |
Ponatinib HCl Tab |
30 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Iclusig |
Ponatinib HCl Tab |
45 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Idhifa |
Enasidenib Mesylate Tab 100 MG (Base Equivalent) |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Idhifa |
Enasidenib Mesylate Tab 50 MG (Base Equivalent) |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Imbruvica |
Ibrutinib Cap |
70 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Imbruvica |
Ibrutinib Cap |
140 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Imbruvica |
Ibrutinib Oral Susp |
70 MG/ML |
2 |
Bottles |
30 |
DAYS |
|
|
|
Imbruvica |
ibrutinib tab |
140 MG ; 280 MG ; 420 MG ; 560 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Inlyta |
Axitinib Tab |
1 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Inlyta |
Axitinib Tab |
5 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
5 |
Tablets |
28 |
DAYS |
|
|
|
Inrebic |
Fedratinib HCl Cap 100 MG |
100 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Iressa |
gefitinib tab |
250 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Iwilfin |
eflornithine hcl tab |
192 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Jakafi |
ruxolitinib phosphate tab |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Jaypirca |
pirtobrutinib tab |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Jaypirca |
pirtobrutinib tab |
100 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Kisqali |
Ribociclib Succinate Tab Pack 200 MG Daily Dose |
200 MG |
21 |
Tablets |
28 |
DAYS |
|
|
|
Kisqali |
Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab) |
200 MG |
42 |
Tablets |
28 |
DAYS |
|
|
|
Kisqali |
Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab) |
200 MG |
63 |
Tablets |
28 |
DAYS |
|
|
|
Kisqali femara 200 dose |
Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
49 |
Tablets |
28 |
DAYS |
|
|
|
Kisqali femara 400 dose |
Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
70 |
Tablets |
28 |
DAYS |
|
|
|
Kisqali femara 600 dose |
Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
91 |
Tablets |
28 |
DAYS |
|
|
|
Koselugo |
Selumetinib Sulfate Cap 10 MG |
10 MG |
240 |
Capsules |
30 |
DAYS |
|
|
|
Koselugo |
Selumetinib Sulfate Cap 25 MG |
25 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Krazati |
Adagrasib Tab |
200 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Lazcluze |
lazertinib mesylate tab |
80 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Lazcluze |
lazertinib mesylate tab |
240 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Lenvima 10 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 12mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 14 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 & 4 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 18 mg daily dose |
Lenvatinib Cap Ther Pack |
10 MG & 2 x 4 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 20 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 24 mg daily dose |
Lenvatinib Cap Ther Pack |
2 x 10 MG & 4 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 4 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Lenvima 8 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG |
60 |
Tablets |
28 |
DAYS |
|
|
|
Lonsurf |
trifluridine-tipiracil tab |
20-8.19 MG |
80 |
Tablets |
28 |
DAYS |
|
|
|
Lorbrena |
Lorlatinib Tab |
25 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Lorbrena |
Lorlatinib Tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Lumakras |
sotorasib tab |
320 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Lumakras |
Sotorasib Tab |
120 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Lynparza |
olaparib tab |
100 MG ; 150 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
84 |
Tablets |
28 |
DAYS |
|
|
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
112 |
Tablets |
28 |
DAYS |
|
|
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
140 |
Tablets |
28 |
DAYS |
|
|
|
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
1170 |
mLs |
28 |
DAYS |
|
|
|
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent) |
0.5 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent) |
2 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Mektovi |
binimetinib tab |
15 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Nerlynx |
Neratinib Maleate Tab |
40 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Nexavar |
Sorafenib Tosylate Tab 200 MG (Base Equivalent) |
200 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
3 |
Capsules |
28 |
DAYS |
|
|
|
Nubeqa |
Darolutamide Tab 300 MG |
300 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Odomzo |
sonidegib phosphate cap |
200 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Ogsiveo |
nirogacestat hydrobromide tab |
50 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
Ogsiveo |
nirogacestat hydrobromide tab |
150 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
Ojemda |
tovorafenib for oral susp |
25 MG/ML |
96 |
mLs |
28 |
DAYS |
|
|
|
Ojemda |
tovorafenib tab |
100 MG |
24 |
Tablets |
28 |
DAYS |
|
|
|
Ojjaara |
momelotinib dihydrochloride tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Ojjaara |
momelotinib dihydrochloride tab |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Ojjaara |
momelotinib dihydrochloride tab |
200 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Onureg |
azacitidine tab |
200 MG ; 300 MG |
14 |
Tablets |
28 |
DAYS |
|
|
|
Orgovyx |
relugolix tab |
120 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Orserdu |
elacestrant hydrochloride tab |
86 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Orserdu |
elacestrant hydrochloride tab |
345 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Pemazyre |
Pemigatinib Tab 13.5 MG |
13.5 MG |
14 |
Tablets |
21 |
DAYS |
|
|
|
Pemazyre |
Pemigatinib Tab 4.5 MG |
4.5 MG |
14 |
Tablets |
21 |
DAYS |
|
|
|
Pemazyre |
Pemigatinib Tab 9 MG |
9 MG |
14 |
Tablets |
21 |
DAYS |
|
|
|
Piqray 200mg daily dose |
Alpelisib Tab Therapy Pack 200 MG Daily Dose |
200 MG |
28 |
Tablets |
28 |
DAYS |
|
|
|
Piqray 250mg daily dose |
Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs) |
200 & 50 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
Piqray 300mg daily dose |
Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab) |
150 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Qinlock |
Ripretinib Tab |
50 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Retevmo |
Selpercatinib Cap |
40 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Retevmo |
Selpercatinib Cap |
80 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Retevmo |
selpercatinib tab |
40 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Retevmo |
selpercatinib tab |
80 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Retevmo |
selpercatinib tab |
120 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Retevmo |
selpercatinib tab |
160 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Cap 10 MG |
10 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Cap 15 MG |
15 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Cap 20 MG |
20 MG |
21 |
Capsules |
21 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Cap 25 MG |
25 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Cap 5 MG |
5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Revlimid |
Lenalidomide Caps 2.5 MG |
2.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Rezlidhia |
Olutasidenib Cap |
150 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Rozlytrek |
Entrectinib Cap 100 MG |
100 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Rozlytrek |
Entrectinib Cap 200 MG |
200 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Rozlytrek |
entrectinib pellet pack |
50 MG |
336 |
Packets |
28 |
DAYS |
|
|
|
Rubraca |
Rucaparib Camsylate Tab 200 MG (Base Equivalent) |
200 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Rubraca |
Rucaparib Camsylate Tab 250 MG (Base Equivalent) |
250 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Rubraca |
Rucaparib Camsylate Tab 300 MG (Base Equivalent) |
300 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Rydapt |
Midostaurin Cap 25 MG |
25 MG |
240 |
Capsules |
30 |
DAYS |
|
|
|
Scemblix |
Asciminib HCl Tab |
20 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Scemblix |
Asciminib HCl Tab |
40 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Scemblix |
asciminib hcl tab |
100 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
20 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
70 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
80 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Sprycel |
Dasatinib Tab |
140 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Stivarga |
regorafenib tab |
40 MG |
84 |
Tablets |
28 |
DAYS |
|
|
|
Sutent |
Sunitinib Malate Cap 12.5 MG (Base Equivalent) |
12.5 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Sutent |
Sunitinib Malate Cap 25 MG (Base Equivalent) |
25 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Sutent |
Sunitinib Malate Cap 37.5 MG (Base Equivalent) |
37.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Sutent |
Sunitinib Malate Cap 50 MG (Base Equivalent) |
50 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
840 |
Tablets |
28 |
DAYS |
|
|
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Talzenna |
talazoparib tosylate cap |
0.1 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Talzenna |
talazoparib tosylate cap |
0.35 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Talzenna |
Talazoparib Tosylate Cap |
0.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Talzenna |
Talazoparib Tosylate Cap |
0.75 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Talzenna |
Talazoparib Tosylate Cap 0.25 MG (Base Equivalent) |
0.25 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Talzenna |
Talazoparib Tosylate Cap 1 MG (Base Equivalent) |
1 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
Tarceva |
Erlotinib HCl Tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Tarceva |
Erlotinib HCl Tab |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Tazverik |
tazemetostat hbr tab |
200 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Thalomid |
Thalidomide Cap 100 MG |
100 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Thalomid |
Thalidomide Cap 150 MG |
150 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Thalomid |
Thalidomide Cap 200 MG |
200 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Thalomid |
Thalidomide Cap 50 MG |
50 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Tibsovo |
Ivosidenib Tab 250 MG |
250 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Truqap |
capivasertib tab |
160 MG |
64 |
Tablets |
28 |
DAYS |
|
|
|
Truqap |
capivasertib tab |
200 MG |
64 |
Tablets |
28 |
DAYS |
|
|
|
Truqap |
capivasertib tab therapy pack |
160 MG |
64 |
Tablets |
28 |
DAYS |
|
|
|
Truqap |
capivasertib tab therapy pack |
200 MG |
64 |
Tablets |
28 |
DAYS |
|
|
|
Truseltiq |
Infigratinib Phos Cap Pack |
100 & 25 MG |
42 |
Capsules |
28 |
DAYS |
|
|
|
Truseltiq |
Infigratinib Phos Cap Pack |
100 & 25 MG |
42 |
Capsules |
28 |
DAYS |
|
|
|
Truseltiq |
Infigratinib Phos Cap Ther Pack |
25 MG |
42 |
Capsules |
28 |
DAYS |
|
|
|
Truseltiq |
Infigratinib Phos Cap Ther Pack |
25 MG |
63 |
Capsules |
28 |
DAYS |
|
|
|
Truseltiq |
Infigratinib Phos Cap Ther Pack |
100 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
Tukysa |
Tucatinib Tab |
50 MG |
300 |
Tablets |
30 |
DAYS |
|
|
|
Tukysa |
Tucatinib Tab |
150 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Turalio |
Pexidartinib HCl Cap |
125 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Turalio |
Pexidartinib HCl Cap |
200 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Tykerb |
Lapatinib Ditosylate Tab |
250 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG |
28 |
Tablets |
28 |
DAYS |
|
|
|
Vanflyta |
quizartinib dihydrochloride tab |
26.5 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
Venclexta |
Venetoclax Tab 10 MG |
10 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Venclexta |
Venetoclax Tab 100 MG |
100 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
Venclexta |
Venetoclax Tab 50 MG |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Venclexta starting pack |
Venetoclax Tab Therapy Starter Pack 10 & 50 & 100 MG |
10 & 50 & 100 MG |
1 |
Pack |
180 |
DAYS |
|
|
|
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Vitrakvi |
Larotrectinib Sulfate Cap 100 MG (Base Equivalent) |
100 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
Vitrakvi |
Larotrectinib Sulfate Cap 25 MG (Base Equivalent) |
25 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
Vitrakvi |
Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent) |
20 MG/ML |
300 |
mLs |
30 |
DAYS |
|
|
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Vonjo |
Pacritinib Citrate Cap |
100 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Voranigo |
vorasidenib tab |
10 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Voranigo |
vorasidenib tab |
40 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Votrient |
Pazopanib HCl Tab |
200 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Welireg |
Belzutifan Tab |
40 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Xalkori |
crizotinib cap |
200 MG ; 250 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Xalkori |
crizotinib cap sprinkle |
20 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Xalkori |
crizotinib cap sprinkle |
50 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Xalkori |
crizotinib cap sprinkle |
150 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
Xospata |
Gilteritinib Fumarate Tablet |
40 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
4 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
8 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
8 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio |
Selinexor Tab Therapy Pack |
50 MG |
8 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio |
Selinexor Tab Therapy Pack |
60 MG |
4 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio 60 mg twice weekly |
Selinexor Tab Therapy Pack 20 MG (60 MG Twice Weekly) |
20 MG |
24 |
Tablets |
28 |
DAYS |
|
|
|
Xpovio 80 mg twice weekly |
Selinexor Tab Therapy Pack 20 MG (80 MG Twice Weekly) |
20 MG |
32 |
Tablets |
28 |
DAYS |
|
|
|
Xtandi |
enzalutamide cap |
40 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Xtandi |
Enzalutamide Tab |
40 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Xtandi |
Enzalutamide Tab |
80 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Yonsa |
abiraterone acetate tab 125 mg |
125 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Zejula |
niraparib tosylate cap |
100 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
Zejula |
niraparib tosylate tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zejula |
niraparib tosylate tab |
200 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zejula |
niraparib tosylate tab |
300 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
Zelboraf |
Vemurafenib Tab 240 MG |
240 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
Zolinza |
Vorinostat Cap 100 MG |
100 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
Zykadia |
ceritinib tab |
150 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
Zytiga |
Abiraterone Acetate Tab 250 MG |
250 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
Zytiga |
Abiraterone Acetate Tab 500 MG |
500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – PRIOR AUTHORIZATION
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
tretinoin cap |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor ; Torpenz |
everolimus tab |
10 ; 10 MG ; 2.5 ; 2.5 MG ; 5 ; 5 MG ; 7.5 ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor ; Torpenz |
Everolimus Tab 10 MG |
10 ; 10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor ; Torpenz |
Everolimus Tab 5 MG |
5 ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor disperz |
everolimus tab for oral susp |
2 MG ; 3 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG ; 50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
brigatinib tab |
180 MG ; 30 MG ; 90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
brigatinib tab ; brigatinib tab initiation therapy pack |
180 MG ; 30 MG ; 90 & 180 MG ; 90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Augtyro |
repotrectinib cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Balversa |
erdafitinib tab |
3 MG ; 4 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Besremi |
ropeginterferon alfa- |
500 MCG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bosulif |
bosutinib cap ; bosutinib tab |
100 MG ; 400 MG ; 50 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Braftovi |
encorafenib cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Brukinsa |
zanubrutinib cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Brukinsa |
zanubrutinib cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cabometyx |
cabozantinib s-malate tab |
20 MG ; 40 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Calquence |
acalabrutinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Calquence |
acalabrutinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Calquence |
acalabrutinib maleate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cometriq |
cabozantinib s-mal cap ; cabozantinib s-malate cap |
20 MG ; 3 x 20 MG & 80 MG ; 80 & 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cotellic |
cobimetinib fumarate tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Daurismo |
glasdegib maleate tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Erivedge |
vismodegib cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Erleada |
apalutamide tab |
240 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fotivda |
tivozanib hcl cap |
0.89 MG ; 1.34 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fruzaqla |
fruquintinib cap |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gleevec |
imatinib mesylate tab |
100 MG ; 400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Hycamtin |
topotecan hcl cap |
0.25 MG ; 1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ibrance |
palbociclib cap |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ibrance |
palbociclib cap ; palbociclib tab |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iclusig |
ponatinib hcl tab |
10 MG ; 15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Idhifa |
enasidenib mesylate tab |
100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Imbruvica |
ibrutinib cap ; ibrutinib oral susp ; ibrutinib tab |
140 MG ; 280 MG ; 420 MG ; 560 MG ; 70 MG ; 70 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inlyta |
axitinib tab |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inlyta |
axitinib tab |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inrebic |
fedratinib hcl cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iwilfin |
eflornithine hcl tab |
192 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jakafi |
ruxolitinib phosphate tab |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jaypirca |
pirtobrutinib tab |
100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali |
ribociclib succinate tab pack |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali femara 200 dose ; Kisqali femara 400 dose ; Kisqali femara 600 dose |
ribociclib |
200 & 2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Koselugo |
selumetinib sulfate cap |
10 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Krazati |
adagrasib tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lazcluze |
lazertinib mesylate tab |
240 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 10 mg daily dose ; Lenvima 12mg daily dose ; Lenvima 14 mg daily dose ; Lenvima 18 mg daily dose ; Lenvima 20 mg daily dose ; Lenvima 24 mg daily dose ; Lenvima 4 mg daily dose ; Lenvima 8 mg daily dose |
lenvatinib cap ther pack ; lenvatinib cap therapy pack |
10 & 4 MG ; 10 MG ; 10 MG & 2 x 4 MG ; 2 x 10 MG & 4 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG ; 20-8.19 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lumakras |
sotorasib tab |
120 MG ; 320 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lynparza |
olaparib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lysodren |
mitotane tab |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lytgobi |
futibatinib tab therapy pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Matulane |
procarbazine hcl cap |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mekinist |
trametinib dimethyl sulfoxide tab |
0.5 MG ; 2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mektovi |
binimetinib tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nerlynx |
neratinib maleate tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nerlynx |
neratinib maleate tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexavar |
sorafenib tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nubeqa |
darolutamide tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Odomzo |
sonidegib phosphate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG ; 150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojemda |
tovorafenib for oral susp ; tovorafenib tab |
100 MG ; 25 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojjaara |
momelotinib dihydrochloride tab |
100 MG ; 150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Onureg |
azacitidine tab |
200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Orgovyx |
relugolix tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Orserdu |
elacestrant hydrochloride tab |
345 MG ; 86 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pemazyre |
pemigatinib tab |
13.5 MG ; 4.5 MG ; 9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Piqray 200mg daily dose ; Piqray 250mg daily dose ; Piqray 300mg daily dose |
alpelisib tab pack ; alpelisib tab therapy pack |
150 MG ; 200 & 50 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qinlock |
ripretinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qinlock |
ripretinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib cap |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib cap ; selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
lenalidomide cap ; lenalidomide caps |
10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 25 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rezlidhia |
olutasidenib cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozlytrek |
entrectinib cap |
100 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozlytrek |
entrectinib pellet pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rubraca |
rucaparib camsylate tab |
200 MG ; 250 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rydapt |
midostaurin cap |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Scemblix |
asciminib hcl tab |
100 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
dasatinib tab |
100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Stivarga |
regorafenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sutent |
sunitinib malate cap |
12.5 MG ; 25 MG ; 37.5 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
talazoparib tosylate cap |
0.1 MG ; 0.25 MG ; 0.35 MG ; 0.5 MG ; 0.75 MG ; 1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Targretin |
bexarotene cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Targretin |
Bexarotene Gel 1% |
1 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tazverik |
tazemetostat hbr tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Temodar |
temozolomide cap |
100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Thalomid |
thalidomide cap |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tibsovo |
ivosidenib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab |
160 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab therapy pack |
160 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
infigratinib phos cap pack ; infigratinib phos cap ther pack |
100 & 25 MG ; 100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Turalio |
pexidartinib hcl cap |
125 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Turalio |
pexidartinib hcl cap |
125 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tykerb |
lapatinib ditosylate tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tykerb |
lapatinib ditosylate tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG ; 26.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta |
venetoclax tab |
10 MG ; 100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta starting pack |
venetoclax tab therapy starter pack |
10 & 50 & 100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vitrakvi |
larotrectinib sulfate cap |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vitrakvi |
larotrectinib sulfate oral soln |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vonjo |
pacritinib citrate cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Voranigo |
vorasidenib tab |
10 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Votrient |
pazopanib hcl tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Votrient |
pazopanib hcl tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Welireg |
belzutifan tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xalkori |
crizotinib cap ; crizotinib cap sprinkle |
150 MG ; 20 MG ; 200 MG ; 250 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xeloda |
capecitabine tab |
150 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xospata |
gilteritinib fumarate tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xospata |
gilteritinib fumarate tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio ; Xpovio 60 mg twice weekly ; Xpovio 80 mg twice weekly |
selinexor tab therapy pack |
20 MG ; 40 MG ; 50 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xtandi |
enzalutamide cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xtandi |
enzalutamide tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Yonsa |
abiraterone acetate micronized tab |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate tab |
100 MG ; 200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zelboraf |
vemurafenib tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zolinza |
vorinostat cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zykadia |
ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zykadia |
ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zytiga |
abiraterone acetate tab |
250 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
|
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
|
Erlotinib HCl Tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor ; Torpenz |
everolimus tab |
10 ; 10 MG ; 2.5 ; 2.5 MG ; 5 ; 5 MG ; 7.5 ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor disperz |
Everolimus Tab for Oral Susp 2 MG |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor disperz |
Everolimus Tab for Oral Susp 3 MG |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Afinitor disperz |
Everolimus Tab for Oral Susp 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Akeega |
niraparib tosylate-abiraterone acetate tab |
50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
Brigatinib Tab |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
Brigatinib Tab |
180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
Brigatinib Tab |
90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Augtyro |
repotrectinib cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Balversa |
Erdafitinib Tab 3 MG |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Balversa |
Erdafitinib Tab 4 MG |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Balversa |
Erdafitinib Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Besremi |
Ropeginterferon alfa- |
500 MCG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bosulif |
bosutinib cap |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bosulif |
bosutinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bosulif |
Bosutinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Bosulif |
bosutinib tab |
100 MG ; 400 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Braftovi |
encorafenib cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Brukinsa |
Zanubrutinib Cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cabometyx |
Cabozantinib S-Malate Tab |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cabometyx |
Cabozantinib S-Malate Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cabometyx |
Cabozantinib S-Malate Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Calquence |
acalabrutinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Calquence |
acalabrutinib maleate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Caprelsa |
Vandetanib Tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Caprelsa |
Vandetanib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cometriq |
Cabozantinib S-Mal Cap |
80 & 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cometriq |
Cabozantinib S-Mal Cap |
3 x 20 MG & 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cometriq |
Cabozantinib S-Malate Cap |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Cotellic |
cobimetinib fumarate tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Daurismo |
Glasdegib Maleate Tab 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Daurismo |
Glasdegib Maleate Tab 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Erivedge |
Vismodegib Cap 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Erleada |
apalutamide tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Erleada |
Apalutamide Tab 60 MG |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fotivda |
Tivozanib HCl Cap |
1.34 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fotivda |
Tivozanib HCl Cap |
0.89 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fruzaqla |
fruquintinib cap |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Fruzaqla |
fruquintinib cap |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gleevec |
Imatinib Mesylate Tab |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Gleevec |
Imatinib Mesylate Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ibrance |
palbociclib cap ; palbociclib tab |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iclusig |
Ponatinib HCl Tab |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iclusig |
Ponatinib HCl Tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iclusig |
Ponatinib HCl Tab |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iclusig |
Ponatinib HCl Tab |
45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Idhifa |
Enasidenib Mesylate Tab 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Idhifa |
Enasidenib Mesylate Tab 50 MG (Base Equivalent) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Imbruvica |
Ibrutinib Cap |
140 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Imbruvica |
Ibrutinib Cap |
70 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Imbruvica |
Ibrutinib Oral Susp |
70 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Imbruvica |
ibrutinib tab |
140 MG ; 280 MG ; 420 MG ; 560 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inlyta |
Axitinib Tab |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inlyta |
Axitinib Tab |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Inrebic |
Fedratinib HCl Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Iwilfin |
eflornithine hcl tab |
192 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jakafi |
ruxolitinib phosphate tab |
10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jaypirca |
pirtobrutinib tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Jaypirca |
pirtobrutinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali |
Ribociclib Succinate Tab Pack 200 MG Daily Dose |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali |
Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali |
Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali femara 200 dose |
Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali femara 400 dose |
Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Kisqali femara 600 dose |
Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK |
200 & 2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Koselugo |
Selumetinib Sulfate Cap 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Koselugo |
Selumetinib Sulfate Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Krazati |
Adagrasib Tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lazcluze |
lazertinib mesylate tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lazcluze |
lazertinib mesylate tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 10 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 12mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 14 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 & 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 18 mg daily dose |
Lenvatinib Cap Ther Pack |
10 MG & 2 x 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 20 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 24 mg daily dose |
Lenvatinib Cap Ther Pack |
2 x 10 MG & 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 4 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lenvima 8 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lonsurf |
trifluridine-tipiracil tab |
20-8.19 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lorbrena |
Lorlatinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lorbrena |
Lorlatinib Tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lumakras |
sotorasib tab |
320 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lumakras |
Sotorasib Tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lynparza |
olaparib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent) |
0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent) |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Mektovi |
binimetinib tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nerlynx |
Neratinib Maleate Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nexavar |
Sorafenib Tosylate Tab 200 MG (Base Equivalent) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Nubeqa |
Darolutamide Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Odomzo |
sonidegib phosphate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ogsiveo |
nirogacestat hydrobromide tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ogsiveo |
nirogacestat hydrobromide tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojemda |
tovorafenib for oral susp |
25 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojemda |
tovorafenib tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojjaara |
momelotinib dihydrochloride tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojjaara |
momelotinib dihydrochloride tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Ojjaara |
momelotinib dihydrochloride tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Onureg |
azacitidine tab |
200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Orgovyx |
relugolix tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Orserdu |
elacestrant hydrochloride tab |
86 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Orserdu |
elacestrant hydrochloride tab |
345 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pemazyre |
Pemigatinib Tab 13.5 MG |
13.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pemazyre |
Pemigatinib Tab 4.5 MG |
4.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pemazyre |
Pemigatinib Tab 9 MG |
9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Piqray 200mg daily dose |
Alpelisib Tab Therapy Pack 200 MG Daily Dose |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Piqray 250mg daily dose |
Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs) |
200 & 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Piqray 300mg daily dose |
Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab) |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Qinlock |
Ripretinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
Selpercatinib Cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
Selpercatinib Cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Retevmo |
selpercatinib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Cap 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Cap 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Cap 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Cap 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Revlimid |
Lenalidomide Caps 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rezlidhia |
Olutasidenib Cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozlytrek |
Entrectinib Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozlytrek |
Entrectinib Cap 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rozlytrek |
entrectinib pellet pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rubraca |
Rucaparib Camsylate Tab 200 MG (Base Equivalent) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rubraca |
Rucaparib Camsylate Tab 250 MG (Base Equivalent) |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rubraca |
Rucaparib Camsylate Tab 300 MG (Base Equivalent) |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Rydapt |
Midostaurin Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Scemblix |
Asciminib HCl Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Scemblix |
asciminib hcl tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Scemblix |
Asciminib HCl Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
70 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
140 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sprycel |
Dasatinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Stivarga |
regorafenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sutent |
Sunitinib Malate Cap 12.5 MG (Base Equivalent) |
12.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sutent |
Sunitinib Malate Cap 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sutent |
Sunitinib Malate Cap 37.5 MG (Base Equivalent) |
37.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Sutent |
Sunitinib Malate Cap 50 MG (Base Equivalent) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
talazoparib tosylate cap |
0.1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
talazoparib tosylate cap |
0.35 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
Talazoparib Tosylate Cap |
0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
Talazoparib Tosylate Cap |
0.75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
Talazoparib Tosylate Cap 0.25 MG (Base Equivalent) |
0.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Talzenna |
Talazoparib Tosylate Cap 1 MG (Base Equivalent) |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tarceva |
Erlotinib HCl Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tarceva |
Erlotinib HCl Tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tazverik |
tazemetostat hbr tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Thalomid |
Thalidomide Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Thalomid |
Thalidomide Cap 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Thalomid |
Thalidomide Cap 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Thalomid |
Thalidomide Cap 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tibsovo |
Ivosidenib Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab therapy pack |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truqap |
capivasertib tab therapy pack |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
Infigratinib Phos Cap Pack |
100 & 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
Infigratinib Phos Cap Pack |
100 & 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
Infigratinib Phos Cap Ther Pack |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
Infigratinib Phos Cap Ther Pack |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Truseltiq |
Infigratinib Phos Cap Ther Pack |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tukysa |
Tucatinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tukysa |
Tucatinib Tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Turalio |
Pexidartinib HCl Cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Turalio |
Pexidartinib HCl Cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Tykerb |
Lapatinib Ditosylate Tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vanflyta |
quizartinib dihydrochloride tab |
26.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta |
Venetoclax Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta |
Venetoclax Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta |
Venetoclax Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Venclexta starting pack |
Venetoclax Tab Therapy Starter Pack 10 & 50 & 100 MG |
10 & 50 & 100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vitrakvi |
Larotrectinib Sulfate Cap 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vitrakvi |
Larotrectinib Sulfate Cap 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vitrakvi |
Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent) |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Vonjo |
Pacritinib Citrate Cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Voranigo |
vorasidenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Voranigo |
vorasidenib tab |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Votrient |
Pazopanib HCl Tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Welireg |
Belzutifan Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xalkori |
crizotinib cap |
200 MG ; 250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xalkori |
crizotinib cap sprinkle |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xalkori |
crizotinib cap sprinkle |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xalkori |
crizotinib cap sprinkle |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xospata |
Gilteritinib Fumarate Tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio |
Selinexor Tab Therapy Pack |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio |
Selinexor Tab Therapy Pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio 60 mg twice weekly |
Selinexor Tab Therapy Pack 20 MG (60 MG Twice Weekly) |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xpovio 80 mg twice weekly |
Selinexor Tab Therapy Pack 20 MG (80 MG Twice Weekly) |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xtandi |
enzalutamide cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xtandi |
Enzalutamide Tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Xtandi |
Enzalutamide Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Yonsa |
abiraterone acetate tab 125 mg |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zejula |
niraparib tosylate tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zelboraf |
Vemurafenib Tab 240 MG |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zolinza |
Vorinostat Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zykadia |
ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zytiga |
Abiraterone Acetate Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
Zytiga |
Abiraterone Acetate Tab 500 MG |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
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PA QL |
NOTE: brand Gleevec and brand Nexavar to be managed through generic before brand requirement *Preferred Agents may be targeted in another utilization management program and require Prior Authorization Initial Evaluation Target Agent(s) will be approved when ALL of the following are met:
Compendia Allowed: NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A Length of Approval*: titration requests over the program quantity limit or Vitrakvi - up to 3 months; all other requests - up to 12 months *Approve starter packs and loading doses where appropriate and maintenance dose for the remainder of the authorization. NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. **Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.
Renewal Evaluation Target Agent(s) will be approved when ALL of the following are met:
Length of Approval: up to 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. FDA Companion Diagnostics: https://www.fda.gov/medical-devices/vitro-diagnostics/list-cleared-or-approved-companion-diagnostic-devices-vitro-and-imaging-tools |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.
ALBP _ Commercial _ CSReg _ Self-Administered_Oncology_Agents_PAQL _ProgSum_ 01-01-2025 _ © Copyright Prime Therapeutics LLC. November 2024 All Rights Reserved