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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   

07-01-2024           

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 approved in FDA labeling and/or supported by NCCN Drugs & Biologics compendia with a category 1 or 2A recommendation, AHFS, or DrugDex with level of evidence of 1 or 2A. 

Safety (3-121)

Agent(s)

Contraindication(s)

Afinitor/Afinitor Disperz (everolimus)

  • Clinically significant hypersensitivity to everolimus, to other rapamycin derivatives

Akeega (niraparib and abiraterone)

  • None

Alecensa (alectinib)

  • None

Alunbrig (brigatinib)

  • None

Augtyro (repotrectinib)

  • None

Ayvakit (avapritinib)

  • None

Balversa (erdafitinib)

  • None

BESREMi (ropeginterferon alfa-2b-njft)

  • Existence of, or history of severe psychiatric disorders, particularly severe depression, suicidal ideation, or suicide attempt
  • Hypersensitivity to interferons including interferon alfa-2b or any of the inactive ingredients of BESREMi
  • Moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment
  • History or presence of active serious or untreated autoimmune disease
  • Immunosuppressed transplant recipients

Bosulif (bosutinib)

  • History of hypersensitivity to bosutinib

Braftovi (encorafenib)

  • None

Brukinsa (zanubrutinib)

  • None

Cabometyx (cabozantinib)

  • None

Calquence (acalabrutinib)

  • None

Caprelsa (vandetanib)

  • Congenital long QT syndrome

Cometriq (cabozantinib)

  • None

Copiktra (duvelisib)

  • None

Cotellic (cobimetinib)

  • None

Daurismo (glasdegib)

  • None

Erivedge (vismodegib)

  • None

Erleada (apalutamide)

  • None

Fotivda (tivozanib)

  • None

Fruzaqla (fruquintinib)

  • None

Gavreto (pralsetinib)

  • None

Gilotrif (afatinib)

  • None

Gleevec (imatinib)

  • None

Hycamtin (topotecan)

  • History of severe hypersensitivity to topotecan

Ibrance (palbociclib)

  • None

Iclusig (ponatinib)

  • None

Idhifa (enasidenib)

  • None

Imbruvica (ibrutinib)

  • None

Inlyta (axitinib)

  • None

Inqovi (decitabine/ cedazuridine)

  • None

Inrebic (fedratinib)

  • None

Iressa (gefitinib)

  • None

Iwilfin (eflornithine)

  • None

Jakafi (ruxolitinib)

  • None

Jaypirca (pirtobrutinib) 

  • None

Kisqali (ribociclib)

  • None

Kisqali Femara Pack (ribociclib and letrozole co-packaged)

  • Known hypersensitivity to letrozole, or any excipients of Femara

Koselugo (selumetinib)

  • None

Krazati (adagrasib)

  • None

Lenvima (lenvatinib)

  • None

Lonsurf (trifluridine/tipiracil)

  • None

Lorbrena (lorlatinib)

  • Concomitant use with a strong CYP3A inducer, due to potential for serious hepatotoxicity 

Lumakras (sotorasib)

  • None

Lynparza (olaparib) tablets

  • None

Lysodren (mitotane)

  • None

Lytgobi (futibatinib)

  • None

Matulane (procarbazine)

  • Known hypersensitivity to procarbazine, inadequate marrow reserve

Mekinist (trametinib)

  • None

Mektovi (binimetinib)

  • None

Nerlynx (neratinib)

  • None

Nexavar (sorafenib)

  • Known severe hypersensitivity to sorafenib or any other component of Nexavar  
  • Use in combination with carboplatin and paclitaxel in patients with squamous cell lung cancer

Ninlaro (ixazomib)

  • None

Nubeqa (darolutamide)

  • None

Odomzo (sonidegib)

  • None

Ojjaara (momelotinib)

  • None

Ogsiveo (nirogacestat)

  • None

Ojemda (tovorafenib)

  • None

Onureg (azacitidine)

  • Known severe hypersensitivity to azacitidine or its components

Orgovyx (relugolix)

  • Known severe hypersensitivity to relugolix or to any of the product components

Orserdu (elacestrant) 

  • None 

Pemazyre (pemigatinib)

  • None

Piqray (alpelisib)

  • Severe hypersensitivity to Piqray or to any of its components

Pomalyst (pomalidomide)

  • Pregnancy
  • Severe hypersensitivity to pomalidomide or any of the excipients

Qinlock (ripretinib)

  • None

Retevmo (selpercatinib)

  • None

Revlimid (lenalidomide)

  • Pregnancy
  • Severe hypersensitivity to lenalidomide

Rezlidhia (olutasidenib)

  • None

Rozlytrek (entrectinib)

  • None

Rubraca (rucaparib)

  • None

Rydapt (midostaurin)

  • Hypersensitivity to midostaurin or any of the excipients

Scemblix (asciminib)

  • None

Sprycel (dasatinib)

  • None

Stivarga (regorafenib)

  • None

Sutent (sunitinib)

  • None

Tabrecta (capmatinib)

  • None

Tafinlar (dabrafenib)

  • None

Tagrisso (osimertinib)

  • None

Talzenna (talazoparib)

  • None

Tarceva (erlotinib)

  • None

Targretin (bexarotene)

capsules

  • Pregnancy
  • Known serious hypersensitivity to bexarotene or other components of the product

Targretin (bexarotene) gel

  • Known serious hypersensitivity to bexarotene or other components of the product

Tasigna (nilotinib)

  • Hypokalemia, hypomagnesemia, long QT syndrome

Tazverik (tazemetostat)

  • None

Temodar (temozolomide)

  • Hypersensitivity to dacarbazine (DTIC)  
  • Hypersensitivity to temozolomide or any other ingredients in Temodar

Tepmetko (tepotinib)

  • None

Thalomid (thalidomide)

  • Pregnancy
  • Demonstrated hypersensitivity to thalidomide or its components

Tibsovo (ivosidenib)

  • None

Tretinoin (oral)

  • Known hypersensitivity to tretinoin, any of its components, or other retinoids

Truqap (capivasertib)

  • Severe hypersensitivity to Truqap or any of its components

Truseltiq (infigratinib)

  • None

Tukysa (tucatinib)

  • None

Turalio (pexidartinib)

  • None

Tykerb (lapatinib)

  • Known hypersensitivity to lapatinib or its components

Vanflyta (quizartinib)

  • Contraindicated in patients with severe hypokalemia, severe hypomagnesemia, long QT syndrome, or in patients with a history of ventricular arrhythmias or torsades de pointes

Venclexta (venetoclax)

  • Concomitant use with strong CYP3A inhibitors at initiation and during ramp-up phase in patients with CLL/SLL

Verzenio (abemaciclib)

  • None

Vitrakvi (larotrectinib)

  • None

Vizimpro (dacomitinib)

  • None

Vonjo (pacritinib)

  • Concomitant use of a strong CYP3A4 inhibitor or inducer

Votrient (pazopanib)

  • None

Welireg (belzutifan)

  • None

Xalkori (crizotinib)

  • None

Xeloda (capecitabine)

  • Severe hypersensitivity to fluorouracil or capecitabine 

 Xospata (gilteritinib)

  • Hypersensitivity to gilteritinib or any of the excipients

Xpovio (selinexor)

  • None

Xtandi (enzalutamide)

  • None

Yonsa (abiraterone acetate)

  • None

Zejula (niraparib)

  • None

Zelboraf (vemurafenib)

  • None

Zolinza (vorinostat)

  • None

Zydelig (idelalisib)

  • History of serious allergic reactions to idelalisib, including anaphylaxis and toxic epidermal necrolysis with any drug

Zykadia (ceritinib)

  • None

Zytiga (abiraterone)

  • None

REFERENCES

Number

Reference

1

Sacco Jj, Botten J, Macbeth F, et al.  The average body surface area of adult cancer patients in the UK:  A multicentre retrospective study.  PLoS ONE 5(1):e8933.  Doi:10.1371/journal.pone.0008933.

2

Verbraecken J et al.  Body surface area in normal-weight, overweight, and obese adults.  A Comparison study.  Metabolism Clinical and Experimental 2006;55:515-524.

3

Afinitor/Afinitor Disperz prescribing information. Novartis Pharmaceuticals Corporation. February 2022.

4

Alecensa prescribing information. Genentech, Inc. September 2021.

5

Alunbrig prescribing information. Takeda Pharmaceuticals America, Inc. February 2022.

6

Ayvakit prescribing information. Blueprint Medicines Corp. March 2023.

7

Balversa prescribing information. Janssen Products, LP. January 2023.

8

BESREMi prescribing information. Pharmaessentia USA. November 2021.

9

Bosulif prescribing information. Pfizer Laboratories Div of Pfizer Inc. September 2023.

10

Braftovi prescribing information. Array BioPharma Inc. February 2022.

11

Brukinsa prescribing information. BeiGene, USA, Inc. April 2023.

12

Cabometyx prescribing information. Exelixis, Inc. January 2023.

13

Calquence prescribing information. AstraZeneca Pharmaceuticals LP. March 2022.

14

Caprelsa prescribing information. Genzyme Corporation. March 2022.

15

Cometriq prescribing information. Exelixis, Inc. February 2022.

16

Copiktra prescribing information. Secura Bio, Inc. February 2022.

17

Cotellic prescribing information. Genentech, Inc. November 2022.

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. February 2023.

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. February 2022.

25

Gilotrif prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. April 2022.

26

Gleevec prescribing information. Novartis Pharmaceuticals Corporation. August 2022.

27

Hycamtin prescribing Information. Novartis Pharmaceuticals Corporation. September 2018.

28

Ibrance prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2022.

29

Iclusig prescribing information. Takeda Pharmaceuticals America, Inc. February 2022.

30

Idhifa prescribing information. Celgene Corporation. August 2022.

31

Imbruvica prescribing information. Pharmacyclics, Inc. August 2022.

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. October 2022.

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. October 2022.

38

Kisqali prescribing information. Novartis Pharmaceuticals Corporation. October 2022.

39

Koselugo prescribing information. AstraZeneca Pharmaceuticals LP. December 2021.

40

Lenvima prescribing information. Eisai Inc. November 2022.

41

Lonsurf prescribing information. Taiho Oncology, Inc. January 2020.

42

Lorbrena prescribing information. Pfizer Laboratories Div Pfizer Inc. March 2021.

43

Lumakras prescribing information. Amgen Inc. January 2023.

44

Lynparza tablets prescribing information. AstraZeneca Pharmaceuticals LP. October 2022.

45

Lysodren prescribing information. HRA Pharma Rare Diseases. June 2021.

46

Matulane prescribing information. Leadiant Biosciences. August 2018.

47

Mekinist prescribing information. Novartis Pharmaceuticals Corporation. March 2023.

48

Mektovi prescribing information. Array BioPharma Inc. November 2020.

49

Nerlynx prescribing information. Puma Biotech. March 2022.

50

Nexavar prescribing information. Bayer HealthCare Pharmaceuticals Inc. May 2021.

51

Ninlaro prescribing information. Takeda Pharmaceuticals America, Inc. November 2022.

52

Nubeqa prescribing information. Bayer HealthCare Pharmaceuticals Inc. August 2022.

53

Odomzo prescribing information. Sun Pharmaceutical Industries, Inc. May 2019.

54

Onureg prescribing information. Celgene Corporation. October 2022.

55

Orgovyx prescribing information. Myovant Sciences, Inc. March 2023.

56

Pemazyre prescribing information. Incyte Corporation. August 2022.

57

Piqray prescribing information. Novartis Pharmaceuticals Corp. May 2022.

58

Pomalyst prescribing information. Celgene Corporation. March 2023.

59

Qinlock prescribing information. Deciphera Pharmaceuticals, LLC. December 2022.

60

Retevmo prescribing information. Eli Lilly and Company. September 2022.

61

Revlimid prescribing information. Celgene Corporation. March 2023.

62

Rozlytrek prescribing information. Genentech USA, Inc. October 2023.

63

Rubraca prescribing information. Clovis Oncology, Inc. December 2022.

64

Rydapt prescribing information. Novartis Pharmaceuticals Corporation. November 2021.

65

Scemblix prescribing information. Novartis Pharmsceuticals Corporation. October 2022.

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 2023.

70

Tafinlar prescribing information. Novartis Pharmaceuticals Corporation. March 2023.

71

Tagrisso prescribing information. AstraZeneca Pharmaceuticals LP. October 2022.

72

Talzenna prescribing information. Pfizer Laboratories Div Pfizer Inc. June 2023.

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. September 2021.

77

Tazverik prescribing information. Epizyme Inc. July 2020.

78

Temodar prescribing Information. Merck Sharp & Dohme Corp. November 2022.

79

Tepmetko prescribing information. EMD Serono, Inc. March 2023.

80

Thalomid prescribing information. Celgene Corporation. March 2023.

81

Tibsovo prescribing information. ServierPharmaceutical LLC, Inc. May 2022.

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. December 2022.

86

Tykerb prescribing information. Novartis Pharmaceuticals Corporation. March 2022.

87

Reference is no longer used

88

Venclexta prescribing information. AbbVie Inc. June 2022.

89

Verzenio prescribing information. Eli Lilly and Company. March 2023.

90

Vitrakvi prescribing information. Bayer HealthCare Pharmaceuticals Inc. December 2022.

91

Vizimpro prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2020.

92

Votrient prescribing information. Novartis Pharmaceuticals Corporation. December 2021.

93

Welireg prescribing information. Merck Sharp & Dohme LLC. May 2022.

94

Xalkori prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2023.

95

Xeloda prescribing information. H2-Pharma, LLC. 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. September 2022.

99

Yonsa prescribing information. Sun Pharmaceuticals Industries, Inc. March 2022.

100

Zejula capsule prescribing information. GSK LLC. April 2023.

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. February 2022.

107

Lytgobi prescribing information. Taiho Pharmaceutical Co., LTD.  September 2022. 

108

Rezlidhia prescribing information. Rigel Pharmaceuticals, Inc. December 2022. 

109

Krazati prescribing information. Mirati Therapeutics, Inc. December 2022. 

110

Jaypirca prescribing information. Eli Lilly and Company. January 2023. 

111

Orserdu prescribing information. Stemline Therapeutics, Inc. January 2023. 

112

Zejula tablet prescribing information. GlaxoSmithKline. April 2023.

113

Vanflyta prescribing information. Daiichi Sankyo Inc. July 2023.

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. Bristol-Myers Squibb Company. November 2023.

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. April 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

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

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

N

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

everolimus tab

10 MG ; 2.5 MG ; 5 MG ; 7.5 MG

M ; N ; O ; Y

O ; Y

Afinitor

Everolimus Tab 10 MG

10 MG

M ; N ; O ; Y

O ; Y

Afinitor

Everolimus Tab 5 MG

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

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

Farydak

panobinostat lactate cap

10 MG ; 15 MG ; 20 MG

M ; N ; O ; Y

N

Votrient

pazopanib hcl tab

200 MG

M ; N ; O ; Y

N ; O ; Y

Votrient

pazopanib hcl tab

200 MG

M ; N ; O ; Y

N ; 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

N

Gavreto

pralsetinib cap

100 MG

M ; N ; O ; Y

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

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  ; 0.1 MG ; 0.25  ; 0.25 MG ; 0.35  ; 0.35 MG ; 0.5  ; 0.5 MG ; 0.75  ; 0.75 MG ; 1  ; 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

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

Selinexor Tab Therapy Pack 20 MG (100 MG Once Weekly)

20

Tablets

28

DAYS

Selinexor Tab Therapy Pack 20 MG (40 MG Once Weekly)

8

Tablets

28

DAYS

Selinexor Tab Therapy Pack 20 MG (40 MG Twice Weekly)

16

Tablets

28

DAYS

Selinexor Tab Therapy Pack 20 MG (60 MG Once Weekly)

12

Tablets

28

DAYS

Selinexor Tab Therapy Pack 20 MG (80 MG Once Weekly)

16

Tablets

28

DAYS

Afinitor

everolimus tab

10 MG ; 2.5 MG ; 5 MG ; 7.5 MG

30

Tablets

30

DAYS

Afinitor disperz

Everolimus Tab for Oral Susp 2 MG

2 MG

60

Tablets

30

DAYS

Calculation is based on 4.5 mg/m2 with a standard BSA of 2.0 and rounding up to nearest full dose

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

Farydak

panobinostat lactate cap

10 MG ; 15 MG ; 20 MG

6

Capsules

21

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

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

The quantity limits for Pomalyst  are based on dosing for  multiple myeloma, which is given daily  for 21 days of a 28 day cycle

Qinlock

Ripretinib Tab

50 MG

90

Tablets

30

DAYS

Retevmo

Selpercatinib Cap

40 MG

180

Capsules

30

DAYS

Retevmo

Selpercatinib Cap

80 MG

120

Capsules

30

DAYS

Revlimid

Lenalidomide Cap 10 MG

10 MG

30

Capsules

30

DAYS

Revlimid

Lenalidomide Cap 15 MG

15 MG

21

Capsules

28

DAYS

The quantity limits for Revlimid 15 mg &  25 mg  capsules are based on dosing for  multiple myeloma, which is 25 mg daily  for 21 days of a 28 day cycle

Revlimid

Lenalidomide Cap 20 MG

20 MG

21

Capsules

21

DAYS

Revlimid

Lenalidomide Cap 25 MG

25 MG

21

Capsules

28

DAYS

The quantity limits for Revlimid 15 mg &  25 mg  capsules are based on dosing for  multiple myeloma, which is 25 mg daily  for 21 days of a 28 day cycle

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