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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). 

Safety

Agents

Boxed Warnings and Contraindications

Afinitor/Afinitor Disperz (everolimus)(3)

Contraindicated in patients with clinically significant hypersensitivity to everolimus or to other rapamycin derivatives.

Akeega (niraparib and abiraterone)(114)

None

Alecensa (alectinib)(4)

None

Alunbrig (brigatinib)(5)

None

Augtyro (repotrectinib)(118)

None

Ayvakit (avapritinib)(6)

None

Balversa (erdafitinib)(7)

None

BESREMi (ropeginterferon alfa-2b-njft)(8)

BESREMi has a boxed warning for risk of serious disorders:

  • Interferon alfa products may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders. Patients should be monitored closely with periodic clinical and laboratory evaluations. Therapy should be withdrawn in patients with persistently severe or worsening signs or symptoms of these conditions. In many, but not all cases, these disorders resolve after stopping therapy.

BESREMi is contraindicated in patients with:

  • 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.
  • History of transplantation and receiving immunosuppressant agents.

Bosulif (bosutinib)(9)

Contraindicated in patients with a history of hypersensitivity to bosutinib.

Braftovi (encorafenib)(10)

None

Brukinsa (zanubrutinib)(11)

None

Cabometyx (cabozantinib)(12)

None

Calquence (acalabrutinib)(13)

None

Caprelsa (vandetanib)(14)

Caprelsa has a boxed warning for QT prolongation, torsades de pointes, and sudden death:

  • Caprelsa can prolong the QT interval. Torsades de pointes and sudden death have occurred in patients receiving Caprelsa. Do not use Caprelsa in patients with hypocalcemia, hypokalemia, hypomagnesemia, or long QT syndrome. Correct hypocalcemia, hypokalemia and/or hypomagnesemia prior to Caprelsa administration. Monitor electrolytes periodically. Avoid drugs known to prolong the QT interval. 

Contraindicated in patients with congenital long QT syndrome.

Cometriq (cabozantinib)(15)

None

Copiktra (duvelisib)(16)

Copiktra has a boxed warning for treatment-related mortality and serious toxicities: infections, diarrhea or colitis, cutaneous reactions, and pneumonitis:

  • Treatment-related mortality occurred in 15% of Copiktra-treated patients.
  • Fatal and/or serious infections occurred in 31% of Copiktra-treated patients. Monitor for signs and symptoms of infection. Withhold Copiktra if infection is suspected.
  • Fatal and/or serious diarrhea or colitis occurred in 18% of Copiktra-treated patients. Monitor for the development of severe diarrhea or colitis. Withhold Copiktra.
  • Fatal and/or serious cutaneous reactions occurred in 5% of Copiktra-treated patients. Withhold Copiktra. 
  • Fatal and/or serious pneumonitis occurred in 5% of COPIKTRA-treated patients. Monitor for pulmonary symptoms and interstitial infiltrates. Withhold Copiktra.

Copiktra has no contraindications of use. 

Cotellic (cobimetinib)(17)

None

Daurismo (glasdegib)(18)

Daurismo has a boxed warning for embryo-fetal toxicity: 

  • Daurismo can cause embryo-fetal death or severe birth defects when administered to a pregnant woman. Daurismo is embryotoxic, fetotoxic, and teratogenic in animals.
  • Conduct pregnancy testing in females of reproductive potential prior to initiation of Daurismo treatment. Advise females of reproductive potential to use effective contraception during treatment with Daurismo and for at least 30 days after the last dose.
  • Advise males of the potential risk of Daurismo exposure through semen and to use condoms with a pregnant partner or a female partner of reproductive potential during treatment with Daurismo and for at least 30 days after the last dose to avoid potential drug exposure.

Daurismo has no contraindications of use. 

Erivedge (vismodegib)(19)

Erivedge has a boxed warning for embryo-fetal toxicity:

  • Erivedge can cause embryo-fetal death or severe birth defects when administered to a pregnant woman. Erivedge is embryotoxic, fetotoxic, and teratogenic in animals. Teratogenic effects included severe midline defects, missing digits, and other irreversible malformations.
  • Verify the pregnancy status of females of reproductive potential within 7 days prior to initiating Erivedge. Advise pregnant women of the potential risks to a fetus. Advise females of reproductive potential to use effective contraception during and after Erivedge.
  • Advise males of the potential risk of Erivedge exposure through semen and to use condoms with a pregnant partner or a female partner of reproductive potential.

Erivedge has no contraindications of use. 

Erleada (apalutamide)(20)

None

Fotivda (tivozanib)(23)

None

Fruzaqla (fruquintinib)(116)

None

Gavreto (pralsetinib)(24)

None

Gilotrif (afatinib)(25)

None

Gleevec (imatinib)(26)

None

Hycamtin (topotecan)(27)

Hycamtin has a boxed warning for myelosuppression:

  • Hycamtin can cause severe myelosuppression. Administer first cycle only to patients with baseline neutrophil counts of greater than or equal to 1,500/mm^3 and platelet counts greater than or equal to 100,000/mm^3. Monitor blood cell counts.

Contraindicated in patients with a history of severe hypersensitivity to topotecan.

Ibrance (palbociclib)(28)

None

Iclusig (ponatinib)(29)

Iclusig has a boxed warning for arterial occlusive events, venous thromboembolic events (VTE), heart failure, and hepatotoxicity:

  • Arterial occlusive events (AOEs), including fatalities, have occurred in Iclusig-treated patients. AOEs included fatal myocardial infarction, stroke, stenosis of large arterial vessels of the brain, severe peripheral vascular disease, and the need for urgent revascularization procedures. Patients with and without cardiovascular risk factors, including patients age 50 years or younger, experienced these events. Monitor for evidence of AOEs. Interrupt or discontinue Iclusig based on severity.
  • VTEs have occurred in Iclusig-treated patients. Monitor for evidence of VTEs. Interrupt or discontinue Iclusig based on severity.
  • Heart failure, including fatalities, occurred in Iclusig-treated patients. Monitor for heart failure and manage patients as clinically indicated. Interrupt or discontinue Iclusig for new or worsening heart failure.
  • Hepatotoxicity, liver failure and death have occurred in Iclusig-treated patients. Monitor liver function tests. Interrupt or discontinue Iclusig based on severity.

Iclusig has no contraindications of use. 

Idhifa (enasidenib)(30)

Idhifa has a boxed warning for differentiation syndrome:

  • Patients treated with Idhifa have experienced symptoms of differentiation syndrome, which can be fatal if not treated. Symptoms may include fever, dyspnea, acute respiratory distress, pulmonary infiltrates, pleural or pericardial effusions, rapid weight gain or peripheral edema, lymphadenopathy, bone pain, and hepatic, renal, or multi-organ dysfunction. If differentiation syndrome is suspected, initiate corticosteroid therapy and hemodynamic monitoring until symptom resolution.

Idhifa has no contraindications of use. 

Imbruvica (ibrutinib)(31)

None

Inlyta (axitinib)(32)

None

Inqovi (decitabine/ cedazuridine)(33)

None

Inrebic (fedratinib)(34)

Inrebic has a boxed warning for encephalopathy including Wernicke's: 

  • Serious and fatal encephalopathy, including Wernicke's, has occurred in patients treated with Inrebic. Wernicke's encephalopathy is a neurologic emergency. Assess thiamine levels in all patients prior to starting Inrebic, periodically during treatment, and as clinically indicated. Do not start Inrebic in patients with thiamine deficiency; replete thiamine prior to treatment initiation. If encephalopathy is suspected, immediately discontinue Inrebic and initiate parenteral thiamine. Monitor until symptoms resolve or improve and thiamine levels normalize. 

Inrebic has no contraindications of use. 

Iressa (gefitinib)(35)

None

Iwilfin (eflornithine)(120)

None

Jakafi (ruxolitinib)(36)

None

Jaypirca (pirtobrutinib)(110) 

None

Kisqali (ribociclib)(38)

None

Kisqali Femara Pack (ribociclib and letrozole co-packaged)(37)

Contraindicated in patients with known hypersensitivity to letrozole or any excipients of Femara.

Koselugo (selumetinib)(39)

None

Krazati (adagrasib)(109)

None

Lazcluze (lazertinib)(2)

None

Lenvima (lenvatinib)(40)

None

Lonsurf (trifluridine/tipiracil)(41)

None

Lorbrena (lorlatinib)(42)

Contraindicated in concomitant use with a strong CYP3A inducer, due to potential for serious hepatotoxicity.

Lumakras (sotorasib)(43)

None

Lynparza (olaparib)(44)

None

Lysodren (mitotane)(45)

Lysodren has a boxed warning for adrenal crisis in the setting of shock, severe trauma or infection:

  • Patients treated with Lysodren are at increased risk for developing adrenal crisis in the setting of shock, severe trauma or infection that may lead to death.
  • If shock, severe trauma or infection occurs or develops, temporarily discontinue Lysodren and administer exogenous steroids. Monitor patients closely for infections and instruct patients to contact their physician immediately if injury, infection, or any other concomitant illness occurs.

Lysodren has no contraindications of use. 

Lytgobi (futibatinib)(107)

None

Matulane (procarbazine)(46)

Matulane has a boxed warning that recommends that Matulane be given only by or under the supervision of a physician experienced in the use of potent antineoplastic drugs. Adequate clinical and laboratory facilities should be available to patients for proper monitoring of treatment. 

Contraindicated in patients with known hypersensitivity to the drug or inadequate marrow reserve as demonstrated by bone marrow aspiration. 

Mekinist (trametinib)(47)

None

Mektovi (binimetinib)(48)

None

Nerlynx (neratinib)(49)

None

Nexavar (sorafenib)(50)

Contraindicated in the following:

  • Patients with known severe hypersensitivity to sorafenib or any other component of Nexavar.
  • Combination with carboplatin and paclitaxel in patients with squamous cell lung cancer.

Ninlaro (ixazomib)(51)

None

Nubeqa (darolutamide)(52)

None

Odomzo (sonidegib)(53)

Odomzo has a boxed warning for embryo-fetal toxicity: 

  • Odomzo can cause embryo-fetal death or severe birth defects when administered to a pregnant woman. Odomzo is embryotoxic, fetotoxic, and teratogenic in animals.
  • Verify the pregnancy status of females of reproductive potential prior to initiating therapy. Advise females of reproductive potential to use effective contraception during treatment with Odomzo and for at least 20 months after the last dose.
  • Advise males of the potential risk of exposure through semen and to use condoms with a pregnant partner or a female partner of reproductive potential during treatment with Odomzo and for at least 8 months after the last dose. 

Odomzo has no contraindications of use. 

Ogsiveo (nirogacestat)(119)

None

Ojemda (tovorafenib)(121)

None

Ojjaara (momelotinib)(115)

None

Onureg (azacitidine)(54)

Contraindicated in patients with history of severe hypersensitivity to azacitidine or its components. 

Orgovyx (relugolix)(55)

Contraindicated in patients with known severe hypersensitivity to relugolix or to any of the product components.

Orserdu (elacestrant)(111)

None

Pemazyre (pemigatinib)(56)

None

Piqray (alpelisib)(57)

Contraindicated in patients with a severe hypersensitivity to Piqray or to any of its components.

Pomalyst (pomalidomide)(58)

Pomalyst has a boxed warning for embryo-fetal toxicity and venous and arterial thromboembolism:

  • Pomalyst is contraindicated in pregnancy. Pomalyst is a thalidomide analogue. Thalidomide is a known human teratogen that causes severe birth defects or embryo-fetal death. In females of reproductive potential, obtain 2 negative pregnancy tests before starting Pomalyst treatment.
  • Deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction, and stroke occur in patients with multiple myeloma treated with Pomalyst. Prophylactic antithrombotic measures were employed in clinical trials. Thromboprophylaxis is recommended, and the choice of regimen should be based on assessment of the patient's underlying risk factors.

Pomalyst is only available through a restricted distribution program called the Pomalyst REMS.

Contraindicated in patients who have demonstrated severe hypersensitivity (e.g., angioedema, anaphylaxis) to pomalidomide or any of the excipients.

Qinlock (ripretinib)(59)

None

Retevmo (selpercatinib)(60)

None

Revlimid (lenalidomide)(61)

Revlimid has a boxed warning for embryo-fetal toxicity, hematologic toxicity, and venous and arterial thromboembolism:

  • Do not use Revlimid during pregnancy. Lenalidomide, a thalidomide analogue, caused limb abnormalities in a developmental monkey study. Thalidomide is a known human teratogen that causes severe life-threatening human birth defects. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death.
  • Revlimid can cause significant neutropenia and thrombocytopenia.
  • Revlimid has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with Revlimid and dexamethasone therapy.

Contraindicated in patients with severe hypersensitivity to lenalidomide. 

Contraindicated in pregnancy and can cause fetal harm when administered to a pregnant female.

Rezlidhia (olutasidenib)(108)

Rezlidhia has a boxed warning for differentiation syndrome:

  • Differentiation syndrome, which can be fatal, can occur with Rezlidhia treatment. Symptoms may include dyspnea, pulmonary infiltrates/pleuropericardial effusion, kidney injury, hypotension, fever, and weight gain.
  • If differentiation syndrome is suspected, withhold Rezlidhia and initiate treatment with corticosteroids and hemodynamic monitoring until symptom resolution. 

Rezlidhia has no contraindications of use. 

Rozlytrek (entrectinib)(62)

None

Rubraca (rucaparib)(63)

None

Rydapt (midostaurin)(64)

Contraindicated in patients with hypersensitivity to midostaurin or any of the excipients.

Scemblix (asciminib)(65)

None

Sprycel (dasatinib)(66)

None

Stivarga (regorafenib)(67)

Stivarga has a boxed warning for hepatotoxicity:

  • Severe and sometimes fatal hepatotoxicity has occurred in clinical trials.
  • Monitor hepatic function prior to and during treatment.
  • Interrupt and then reduce or discontinue Stivarga for hepatotoxicity as manifested by elevated liver function tests or hepatocellular necrosis, depending upon severity and persistence. 

Stivarga has no contraindications of use. 

Sutent (sunitinib)(68)

Sutent has a boxed warning for hepatotoxicity:

  • Hepatotoxicity may be severe, and in some cases, fatal. Monitor hepatic function and interrupt, dose reduce, or discontinue Sutent as recommended. 

Sutent has no contraindications of use. 

Tabrecta (capmatinib)(69)

None

Tafinlar (dabrafenib)(70)

None

Tagrisso (osimertinib)(71)

None

Talzenna (talazoparib)(72)

None

Tarceva (erlotinib)(73)

None

Targretin (bexarotene) 
capsules(74) 

Targretin capsules has a boxed warning for birth defects: 

  • It is a member of the retinoid class of drugs that is associated with birth defects in humans. Targretin must not be administered to a pregnant woman.

Contraindicated in the following:

  • Pregnancy. Targretin can cause fetal harm when administered to a pregnant female. 
  • Patients with a known serious hypersensitivity to bexarotene or other components of the product.

Targretin (bexarotene) gel(75)

Contraindicated in the following:

  • Pregnancy. Targretin can cause fetal harm when administered to a pregnant female. 
  • Patients with known hypersensitivity to bexarotene or other components of the product.

Tasigna (nilotinib)(76)

Tasigna has a boxed warning for QT prolongation and sudden death:

  • Tasigna prolongs the QT interval. Prior to Tasigna administration and periodically, monitor for hypokalemia or hypomagnesemia and correct deficiencies. Obtain ECGs to monitor the QTc at baseline, seven days after initiation, and periodically thereafter, and following any dose adjustments.
  • Sudden deaths have been reported in patients receiving Tasigna. Do not administer Tasigna to patients with hypokalemia, hypomagnesemia, or long QT syndrome.
  • Avoid use of concomitant drugs known to prolong the QT interval and strong CYP3A4 inhibitors. Avoid food 2 hours before and 1 hour after taking the dose.

Contraindicated in patients with known hypokalemia, hypomagnesemia, or long QT syndrome.

Tazverik (tazemetostat)(77)

None

Temodar (temozolomide)(78)

Contraindicated in patients with history of serious hypersensitivity to temozolomide or any other ingredients in Temodar and dacarbazine.

Tepmetko (tepotinib)(79)

None

Thalomid (thalidomide)(80)

Thalomid has a boxed warning for embryo-fetal toxicity and venous thromboembolism:

  • If Thalomid is taken during pregnancy, it can cause severe birth defects or embryo-fetal death and should never be used by females who are pregnant or who could become pregnant while taking the drug. Even a single dose (regardless of strength) taken by a pregnant woman during her pregnancy can cause severe birth defects.
  • The use of Thalomid in multiple myeloma results in an increased risk of venous thromboembolism, such as deep venous thrombosis and pulmonary embolism. This risk increases significantly when Thalomid is used in combination with standard chemotherapeutic agents including dexamethasone. 

Thalomid is available through the Thalomid REMS program approved by the FDA.

Contraindicated in the following:

  • Females who are pregnant.
  • Patients who have demonstrated hypersensitivity to the drug or its components.

Tibsovo (ivosidenib)(81)

Tibsovo has a boxed warning for differentiation syndrome in AML and MDS:

  • Patients treated with Tibsovo have experienced symptoms of differentiation syndrome, which can be fatal. Symptoms may include fever, dyspnea, hypoxia, pulmonary infiltrates, pleural or pericardial effusions, rapid weight gain or peripheral edema, hypotension, and hepatic, renal, or multi-organ dysfunction. If differentiation syndrome is suspected, initiate corticosteroid therapy and hemodynamic monitoring until symptom resolution.

Tibsovo has no contraindications of use.

Tretinoin capsule(82)

Tretinoin has a boxed warning for embryo-fetal toxicity and differentiation syndrome:

  • Tretinoin can cause embryo-fetal loss and malformations when administered to a pregnant woman. Advise pregnant women of the potential risk to a fetus. Females of reproductive potential must have a negative pregnancy test before initiating tretinoin. 
  • Differentiation Syndrome, which can be life-threatening or fatal, occurred in about 26% of patients with APL who received tretinoin. At first signs or symptoms of this syndrome, immediately initiate high-dose corticosteroid therapy and hemodynamic monitoring until resolution of signs and symptoms. Consider withholding tretinoin for moderate and severe Differentiation Syndrome until resolution.  

Contraindicated in patients with known hypersensitivity to tretinoin, any of its components, or other retinoids.

Truqap (capivasertib)(117)

Contraindicated in patients with severe hypersensitivity to Truqap or any of its components.  

Truseltiq (infigratinib)(83)

None

Tukysa (tucatinib)(84)

None

Turalio (pexidartinib)(85)

Turalio has a boxed warning for hepatotoxicity:

  • Turalio can cause serious and potentially fatal liver injury. Monitor liver tests prior to initiation of Turalio and at specified intervals during treatment. Withhold and dose reduce or permanently discontinue Turalio based on severity of hepatotoxicity. Turalio is available only through a restricted program called the Turalio REMS Program. 

Turalio has no contraindications of use.

Tykerb (lapatinib)(83)

Tykerb has a boxed warning for hepatotoxicity:

  • Hepatotoxicity has been observed in clinical trials and postmarketing experience. The hepatotoxicity may be severe and deaths have been reported. Causality of the deaths is uncertain.

Contraindicated in patients with known hypersensitivity to lapatinib or its components.

Vanflyta (quizartinib)(113)

Vanflyta has a boxed warning for QT prolongation, torsades de pointes, and cardiac arrest:

  • Vanflyta prolongs the QT interval in a dose- and concentration-related manner. Prior to Vanflyta administration and periodically, monitor for hypokalemia or hypomagnesemia, and correct deficiencies. Perform ECGs to monitor the QTc at baseline, weekly during induction and consolidation therapy, weekly for at least the first month of maintenance, and periodically thereafter.
  • Torsades de pointes and cardiac arrest have occurred in patients receiving Vanflyta. Do not administer Vanflyta to patients with severe hypokalemia, severe hypomagnesemia, or long QT syndrome.
  • Do not initiate treatment with Vanflyta or escalate the Vanflyta dose if the QT interval corrected by Fridericia's formula (QTcF) is greater than 450 ms.
  • Monitor ECGs more frequently if concomitant use of drugs known to prolong the QT interval is required.
  • Reduce the Vanflyta dose when used concomitantly with strong CYP3A inhibitors, as they may increase quizartinib exposure.
  • Because of the risk of QT prolongation, Vanflyta is available only through a restricted program under the Vanflyta REMS program.

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)(88)

Contraindicated in concomitant use with strong CYP3A inhibitors at initiation and during ramp-up phase in patients with CLL/SLL is contraindicated.

Verzenio (abemaciclib)(89)

None

Vitrakvi (larotrectinib)(90)

None

Vizimpro (dacomitinib)(91)

None

Vonjo (pacritinib)(106)

Contraindicated in concomitant use with a strong CYP3A4 inhibitor or inducer.

Voranigo(1)

None

Votrient (pazopanib)(92)

Votrient has a boxed warning for hepatotoxicity:

  • Severe and fatal hepatotoxicity has been observed in clinical trials. Monitor hepatic function and interrupt, reduce, or discontinue dosing as recommended.

Votrient has no contraindications of use.

Welireg (belzutifan)(93)

Welireg has a boxed warning for embryo-fetal toxicity:

  • Exposure to Welireg during pregnancy can cause embryo-fetal harm.
  • Verify pregnancy status prior to the initiation of Welireg.
  • Advise patients of these risks and the need for effective non-hormonal contraception. Welireg can render some hormonal contraceptives ineffective.

Welireg has no contraindications of use.

Xalkori (crizotinib)(94)

None

Xeloda (capecitabine)(95)

Xeloda has a boxed warning for increased risk of bleeding with concomitant use of vitamin K antagonists:

  • Altered coagulation parameters and/or bleeding, including death, have been reported in patients taking Xeloda concomitantly with oral vitamin K antagonists, such as warfarin.
  • Clinically significant increases in prothrombin time (PT) and international normalized ratio (INR) have been reported in patients who were on stable doses of a vitamin K antagonist at the time Xeloda was introduced. These events occurred within several days and up to several months after initiating Xeloda and, in a few cases, within 1 month after stopping Xeloda. These events occurred in patients with and without liver metastases. Monitor INR more frequently and adjust the dose of the vitamin K antagonist as appropriate.

Contraindicated in patients with a severe hypersensitivity to fluorouracil or capecitabine.

Xospata (gilteritinib)(96)

Xospata has a boxed warning for differentiation syndrome:

  • Patients treated with Xospata have experienced symptoms of differentiation syndrome, which can be fatal or life-threatening if not treated. Symptoms may include fever, dyspnea, hypoxia, pulmonary infiltrates, pleural or pericardial effusions, rapid weight gain or peripheral edema, hypotension, or renal dysfunction. If differentiation syndrome is suspected, initiate corticosteroid therapy and hemodynamic monitoring until symptom resolution.

Contraindicated in patients with hypersensitivity to gilteritinib or any of the excipients.

Xpovio (selinexor)(97)

None

Xtandi (enzalutamide)(98)

None

Yonsa (abiraterone acetate)(99)

None

Zejula (niraparib)(100,112)

None

Zelboraf (vemurafenib)(101)

None

Zolinza (vorinostat)(102)

None

Zydelig (idelalisib)(103)

Zydelig has a boxed warning for fatal and serious toxicities: hepatic, severe diarrhea, colitis, pneumonitis, infections, and intestinal perforation:

  • Fatal and/or serious hepatotoxicity occurred in 16% of Zydelig-treated patients. Monitor hepatic function prior to and during treatment. Interrupt and then reduce or discontinue Zydelig as recommended.
  • Fatal and/or serious and severe diarrhea or colitis occurred in 20% of Zydelig-treated patients. Monitor for the development of severe diarrhea or colitis. Interrupt and then reduce or discontinue Zydelig as recommended.
  • Fatal and/or serious pneumonitis occurred in 4% of Zydelig-treated patients. Monitor for pulmonary symptoms and bilateral interstitial infiltrates. Interrupt or discontinue Zydelig as recommended.
  • Fatal and/or serious infections occurred in 48% of Zydelig-treated patients. Monitor for signs and symptoms of infection. Interrupt Zydelig if infection is suspected.
  • Fatal and serious intestinal perforation can occur in Zydelig-treated patients across clinical trials. Discontinue Zydelig for intestinal perforation.

Contraindicated in patients with a history of serious allergic reactions to idelalisib, including anaphylaxis and toxic epidermal necrolysis with any drug.

Zykadia (ceritinib)(104)

None

Zytiga (abiraterone)(105)

None

 

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

PA

QL

Indications

Preferred Agent(s)

Non-Preferred Agent(s)

Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) in chronic phase

imatinib (generic), Sprycel

Bosulif, Tasigna

Ph+ CML in chronic phase with the T315I mutation

Iclusig

Scemblix

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:

  1. ONE of the following:
    1. The patient has been treated with the requested agent within the past 180 days OR
    2. The prescriber states the patient is being treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
    3. ALL of the following:
      1. ONE of the following:
        1. The patient has an FDA labeled indication for the requested agent and route of administration OR
        2. The patient has an indication that is supported in compendia for the requested agent and route of administration (i.e., this indication must be supported in compendia by ALL requirements [e.g., performance status, disease severity, previous failures, monotherapy vs combination therapy) AND 
      2. If the patient has an FDA labeled indication, then ONE of the following:
        1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
        2. There is support for using the requested agent for the patient’s age for the requested indication AND
      3. ONE of the following:
        1. The requested indication does NOT require specific genetic/diagnostic testing per FDA labeling or compendia for the requested agent OR
        2. The requested indication requires specific genetic/diagnostic testing per FDA labeling or compendia for the requested agent AND BOTH of the following:
          1. Specific genetic/diagnostic testing has been completed AND
          2. The results of the specific genetic/diagnostic testing indicate therapy with the requested agent is appropriate AND
      4. ONE of the following:
        1. The requested agent will be used as monotherapy AND is approved for use as monotherapy within FDA labeling or compendia for the requested indication OR
        2. The requested agent will be used as combination therapy with all agents and/or treatments (e.g., radiation) AND is approved for use as combination therapy with all agents and/or treatments within FDA labeling or compendia for the requested indication AND
      5. ONE of the following:
        1. The requested agent will be used as a first-line agent AND is a first-line agent within FDA labeling or compendia for the requested indication OR
        2. The patient has tried and had an inadequate response to the appropriate number and types of prerequisite agents within FDA labeling or compendia for the requested indication OR
        3. The patient has an intolerance or hypersensitivity to the appropriate number and types of prerequisite agents within FDA labeling or compendia for the requested indication OR
        4. The patient has an FDA labeled contraindication to ALL of the required prerequisite agents within FDA labeling or compendia for the requested indication AND
      6. ONE of the following:

Indication(s)

Preferred Agent(s)

Non-Preferred Agent(s)

Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) in chronic phase

imatinib (generic), Sprycel

Bosulif, Tasigna

Ph+ CML in chronic phase with the T315I mutation

Iclusig

Scemblix

        1. The requested agent is a preferred agent for the requested indication OR
        2. The requested agent is a non-preferred agent for the requested indication AND ONE of the following:
          1. The patient has a medication history of use of ONE preferred agent for the requested indication OR
          2. The patient has an intolerance or hypersensitivity to ONE preferred agent for the requested indication OR
          3. The patient has an FDA labeled contraindication to ALL preferred agents for the requested indication OR
          4. BOTH of the following:
            1. NCCN does NOT specify the plan preferred agent as a preferred regimen for the requested indication AND
            2. NCCN specifies the requested agent as a preferred regimen for the requested indication OR
          5. There is support for the non-preferred agent over the preferred agent for the requested indication OR
          6. If the requested agent is Bosulif or Tasigna for CML, then the patient has been previously treated with Bosulif OR Tasigna for CML AND
      1. If the requested agent is Imbruvica 140 mg or 280 mg tablets, then ONE of the following:
        1. The patient has tried and had an inadequate response to Imbruvica 140 mg capsules OR
        2. The patient has an intolerance or hypersensitivity to Imbruvica 140 mg capsules that is not expected to occur with Imbruvica tablets OR
        3. The patient has an FDA labeled contraindication to Imbruvica 140 mg capsules that is not expected to occur with Imbruvica tablets AND
      2. If the requested agent is Zytiga/abiraterone 500 mg, then ONE of the following:
        1. The patient has tried and had an inadequate response to generic abiraterone 250 mg tablets OR
        2. The patient has an intolerance or hypersensitivity to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent OR
        3. The patient has an FDA labeled contraindication to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent AND
      3. If the requested agent is Mekinist oral solution, then ONE of the following:
        1. The patient weighs less than 26 kg OR
        2. The patient has tried and had an inadequate response to Mekinist oral tablets OR
        3. The patient has an intolerance or hypersensitivity to Mekinist oral tablets that is not expected to occur with the requested agent OR
        4. The patient has an FDA labeled contraindication to Mekinist oral tablets that is not expected to occur with the requested agent OR
        5. There is support for the use of the requested agent over Mekinist oral tablets (e.g., swallowing difficulties) AND
      4. If the requested agent is Bosulif capsules, then ONE of the following:
        1. The requested dose is less than 500 mg OR
        2. There is support for the use of the capsules over the Bosulif tablets (e.g., swallowing difficulties) AND
  1. If the request is for one of the following brand agents with an available generic equivalent (listed below), then ONE of the following:

Brand

Generic Equivalent

Afinitor

everolimus

Afinitor Disperz

everolimus

Gleevec

imatinib

Iressa

gefitinib

Nexavar

sorafenib

Sutent

sunitinib

Tarceva

erlotinib

Targretin

bexarotene

Temodar

temozolomide

Tykerb

lapatinib

Votrient

pazopanib

Xeloda

capecitabine

Zytiga

abiraterone

    1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent OR
    2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent OR
    3. There is support for the use of the requested brand agent over the generic equivalent AND
  1. The patient does not have any FDA labeled contraindications to the requested agent AND
  2. The patient does not have any FDA labeled limitations of use that are otherwise not supported in NCCN for the requested agent

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:

  1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process [Note: patients not previously approved for the requested agent will require initial evaluation review] AND
  2. If the requested agent is Imbruvica 140 mg or 280 mg tablets, then ONE of the following:
    1. The patient has tried and had an inadequate response to Imbruvica 140 mg capsules OR
    2. The patient has an intolerance or hypersensitivity to Imbruvica 140 mg capsules that is not expected to occur with Imbruvica tablets OR
    3. The patient has an FDA labeled contraindication to Imbruvica 140 mg capsules that is not expected to occur with Imbruvica tablets AND
  3. If the requested agent is Zytiga/abiraterone 500 mg, then ONE of the following:
    1. The patient has tried and had an inadequate response to generic abiraterone 250 mg tablets OR
    2. The patient has an intolerance or hypersensitivity to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent OR
    3. The patient has an FDA labeled contraindication to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent AND
  4. If the requested agent is Mekinist oral solution, then ONE of the following:
    1. The patient weighs less than 26 kg OR
    2. The patient has tried and had an inadequate response to Mekinist oral tablets OR
    3. The patient has an intolerance or hypersensitivity to Mekinist oral tablets that is not expected to occur with the requested agent OR
    4. The patient has an FDA labeled contraindication to Mekinist oral tablets that is not expected to occur with the requested agent OR
    5. There is support for the use of the requested agent over Mekinist oral tablets (e.g., swallowing difficulties) AND
  5. If the requested agent is Bosulif capsules, then ONE of the following:
    1. The requested dose is less than 500 mg OR
    2. There is support for the use of the capsules over the Bosulif tablets (e.g., swallowing difficulties) AND
  6. ONE of the following:
    1. The requested agent is Vitrakvi AND the patient has had clinical benefit (partial response, complete response, or stable disease) with the requested agent OR
    2. The requested agent is NOT Vitrakvi AND
  7. If the request is for one of the following brand agents with a generic equivalent (listed below), then ONE of the following:

Brand

Generic Equivalent

Afinitor

everolimus

Afinitor Disperz

everolimus

Gleevec

imatinib

Iressa

gefitinib

Nexavar

sorafenib

Sutent

sunitinib

Tarceva

erlotinib

Targretin

bexarotene

Temodar

temozolomide

Tykerb

lapatinib

Votrient

pazopanib

Xeloda

capecitabine

Zytiga

abiraterone

    1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent OR
    2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent OR
    3. There is support for the use of the requested brand agent over the generic equivalent AND
  1. The patient does not have any FDA labeled contraindications to the requested agent AND
  2. The patient does not have any FDA labeled limitations of use that are otherwise not supported in NCCN for the requested agent

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:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication

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