Antineoplastics, Oral

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
AFATINIB DIMALEATE GILOTRIF TABLET    
ALECTINIB HCL ALECENSA CAPSULE    
AXITINIB INLYTA TABLET    
BOSUTINIB BOSULIF TABLET    
BRIGATINIB ALUNBRIG TABLET    
CABOZANTINIB S-MALATE COMETRIQ CAPSULE    
CABOZANTINIB S-MALATE CABOMETYX TABLET    
CAPECITABINE CAPECITABINE TABLET    
CAPECITABINE XELODA TABLET    
CERITINIB ZYKADIA CAPSULE    
CRIZOTINIB XALKORI CAPSULE    
DABRAFENIB MESYLATE TAFINLAR CAPSULE    
DASATINIB SPRYCEL TABLET    
ERLOTINIB HCL TARCEVA TABLET    
GEFITINIB IRESSA TABLET    
IBRUTINIB IMBRUVICA CAPSULE    
IDELALISIB ZYDELIG TABLET    
IMATINIB MESYLATE GLEEVEC TABLET    
IMATINIB MESYLATE IMATINIB MESYLATE TABLET    
IXAZOMIB CITRATE NINLARO CAPSULE    
LAPATINIB DITOSYLATE TYKERB TABLET    
LENVATINIB MESYLATE LENVIMA CAPSULE    
MERCAPTOPURINE PURIXAN ORAL SUSP    
MERCAPTOPURINE MERCAPTOPURINE TABLET    
METHOTREXATE SODIUM TREXALL TABLET    
METHOTREXATE SODIUM METHOTREXATE TABLET    
MIDOSTAURIN RYDAPT CAPSULE    
NILOTINIB HCL TASIGNA CAPSULE    
NIRAPARIB TOSYLATE ZEJULA CAPSULE    
OLAPARIB LYNPARZA CAPSULE    
OSIMERTINIB MESYLATE TAGRISSO TABLET    
PALBOCICLIB IBRANCE CAPSULE    
PAZOPANIB HCL VOTRIENT TABLET    
PONATINIB HCL ICLUSIG TABLET    
REGORAFENIB STIVARGA TABLET    
RIBOCICLIB SUCCINATE KISQALI TABLET    
RUCAPARIB CAMSYLATE RUBRACA TABLET    
SORAFENIB TOSYLATE NEXAVAR TABLET    
SUNITINIB MALATE SUTENT CAPSULE    
THIOGUANINE TABLOID TABLET    
TRIFLURIDINE/TIPIRACIL HCL LONSURF TABLET    
VEMURAFENIB ZELBORAF TABLET