Antineoplastics, Other

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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
MITOXANTRONE HCL MITOXANTRONE HCL VIAL N    
ABIRATERONE ACETATE ZYTIGA TABLET    
ADO-TRASTUZUMAB EMTANSINE KADCYLA VIAL    
ALDESLEUKIN PROLEUKIN VIAL    
ALITRETINOIN PANRETIN GEL (GRAM)    
ALTRETAMINE HEXALEN CAPSULE    
AMINOLEVULINIC ACID HCL LEVULAN SOL W/APPL   May 25, 2017
ANASTROZOLE ARIMIDEX TABLET    
ANASTROZOLE ANASTROZOLE TABLET    
ARSENIC TRIOXIDE TRISENOX AMPUL    
ASPARAGINASE (ERWINIA CHRYSAN) ERWINAZE VIAL    
ATEZOLIZUMAB TECENTRIQ VIAL    
AVELUMAB BAVENCIO VIAL    
AZACITIDINE VIDAZA VIAL    
AZACITIDINE AZACITIDINE VIAL    
BCG LIVE BCG (TICE STRAIN) VIAL    
BELINOSTAT BELEODAQ VIAL    
BENDAMUSTINE HCL BENDEKA VIAL    
BENDAMUSTINE HCL TREANDA VIAL    
BEXAROTENE BEXAROTENE CAPSULE    
BEXAROTENE TARGRETIN CAPSULE    
BEXAROTENE TARGRETIN GEL (GRAM)    
BICALUTAMIDE BICALUTAMIDE TABLET    
BICALUTAMIDE CASODEX TABLET    
BLEOMYCIN SULFATE BLEO 15K VIAL    
BLEOMYCIN SULFATE BLEOMYCIN SULFATE VIAL    
BLINATUMOMAB BLINCYTO KIT    
BORTEZOMIB VELCADE VIAL    
BRENTUXIMAB VEDOTIN ADCETRIS VIAL    
BUSULFAN MYLERAN TABLET    
BUSULFAN BUSULFAN VIAL    
BUSULFAN BUSULFEX VIAL    
CABAZITAXEL JEVTANA VIAL    
CARBOPLATIN CARBOPLATIN VIAL    
CARFILZOMIB KYPROLIS VIAL    
CARMUSTINE BICNU VIAL    
CARMUSTINE IN POLIFEPROSAN 20 GLIADEL WAFER    
CETUXIMAB ERBITUX VIAL    
CHLORAMBUCIL LEUKERAN TABLET    
CISPLATIN CISPLATIN VIAL    
CLADRIBINE CLADRIBINE VIAL    
CLOFARABINE CLOLAR VIAL    
CLOFARABINE CLOFARABINE VIAL    
COBIMETINIB FUMARATE COTELLIC TABLET    
CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE CAPSULE    
CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE VIAL    
CYTARABINE CYTARABINE VIAL    
CYTARABINE/PF CYTARABINE VIAL    
DACARBAZINE DACARBAZINE VIAL    
DACTINOMYCIN COSMEGEN VIAL    
DARATUMUMAB DARZALEX VIAL    
DAUNORUBICIN HCL DAUNORUBICIN HCL VIAL    
DECITABINE DACOGEN VIAL    
DECITABINE DECITABINE VIAL    
DEGARELIX ACETATE FIRMAGON VIAL    
DOCETAXEL DOCEFREZ VIAL    
DOCETAXEL DOCETAXEL VIAL    
DOCETAXEL TAXOTERE VIAL    
DOXORUBICIN HCL ADRIAMYCIN VIAL    
DOXORUBICIN HCL DOXORUBICIN HCL VIAL    
DOXORUBICIN HCL PEG-LIPOSOMAL DOXIL VIAL    
DOXORUBICIN HCL PEG-LIPOSOMAL DOXORUBICIN HCL LIPOSOME VIAL    
DURVALUMAB IMFINZI VIAL    
ELOTUZUMAB EMPLICITI VIAL    
ENZALUTAMIDE XTANDI CAPSULE    
EPIRUBICIN HCL ELLENCE VIAL    
EPIRUBICIN HCL EPIRUBICIN HCL VIAL    
ERIBULIN MESYLATE HALAVEN VIAL    
ESTRAMUSTINE PHOSPHATE SODIUM EMCYT CAPSULE    
ETOPOSIDE ETOPOSIDE CAPSULE    
ETOPOSIDE ETOPOSIDE VIAL    
ETOPOSIDE TOPOSAR VIAL    
ETOPOSIDE PHOSPHATE ETOPOPHOS VIAL    
EVEROLIMUS AFINITOR DISPERZ TAB SUSP    
EVEROLIMUS AFINITOR TABLET    
EXEMESTANE EXEMESTANE TABLET    
EXEMESTANE AROMASIN TABLET    
FLOXURIDINE FLOXURIDINE VIAL    
FLUDARABINE PHOSPHATE FLUDARABINE PHOSPHATE VIAL    
FLUOROURACIL TOLAK CREAM (G)    
FLUOROURACIL FLUOROURACIL CREAM (G)    
FLUOROURACIL EFUDEX CREAM (G)    
FLUOROURACIL CARAC CREAM (G)    
FLUOROURACIL FLUOROURACIL SOLUTION    
FLUOROURACIL FLUOROURACIL VIAL    
FLUOROURACIL ADRUCIL VIAL    
FLUTAMIDE FLUTAMIDE CAPSULE    
FULVESTRANT FASLODEX SYRINGE    
GEMCITABINE HCL GEMZAR VIAL    
GEMCITABINE HCL GEMCITABINE HCL VIAL    
HYDROXYUREA HYDREA CAPSULE    
HYDROXYUREA HYDROXYUREA CAPSULE    
IDARUBICIN HCL IDARUBICIN HCL VIAL    
IDARUBICIN HCL IDAMYCIN PFS VIAL    
IFOSFAMIDE IFOSFAMIDE VIAL    
IFOSFAMIDE IFEX VIAL    
IFOSFAMIDE/MESNA IFOSFAMIDE-MESNA KIT    
INGENOL MEBUTATE PICATO GEL (EA)    
INTERFERON ALFA-2B,RECOMB. INTRON A VIAL    
INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE VIAL    
IPILIMUMAB YERVOY VIAL    
IRINOTECAN HCL IRINOTECAN HCL VIAL    
IRINOTECAN HCL CAMPTOSAR VIAL    
IXABEPILONE IXEMPRA VIAL    
KIT Y-90/IBRITUMOMAB/H.ALBUMIN ZEVALIN KIT    
LENALIDOMIDE REVLIMID CAPSULE    
LETROZOLE FEMARA TABLET    
LETROZOLE LETROZOLE TABLET    
LOMUSTINE GLEOSTINE CAPSULE    
MECHLORETHAMINE HCL VALCHLOR GEL (GRAM)    
MECHLORETHAMINE HCL MUSTARGEN VIAL    
MEGESTROL ACETATE MEGESTROL ACETATE TABLET    
MELPHALAN MELPHALAN TABLET    
MELPHALAN ALKERAN TABLET    
MELPHALAN HCL MELPHALAN HCL VIAL    
MELPHALAN HCL ALKERAN VIAL    
MELPHALAN HCL/BETADEX SBES EVOMELA VIAL    
METHOTREXATE SODIUM METHOTREXATE VIAL    
METHOTREXATE SODIUM/PF METHOTREXATE SODIUM VIAL    
METHOTREXATE SODIUM/PF METHOTREXATE VIAL    
MITOMYCIN MITOMYCIN VIAL    
MITOTANE LYSODREN TABLET    
NECITUMUMAB PORTRAZZA VIAL    
NELARABINE ARRANON VIAL    
NILUTAMIDE NILANDRON TABLET    
NILUTAMIDE NILUTAMIDE TABLET    
NIVOLUMAB OPDIVO VIAL    
OBINUTUZUMAB GAZYVA VIAL    
OFATUMUMAB ARZERRA VIAL    
OLARATUMAB LARTRUVO VIAL    
OMACETAXINE MEPESUCCINATE SYNRIBO VIAL    
OXALIPLATIN OXALIPLATIN VIAL    
PACLITAXEL PACLITAXEL VIAL    
PACLITAXEL PROTEIN-BOUND ABRAXANE VIAL    
PANITUMUMAB VECTIBIX VIAL    
PANOBINOSTAT LACTATE FARYDAK CAPSULE    
PEGASPARGASE ONCASPAR VIAL    
PEGINTERFERON ALFA-2B SYLATRON KIT    
PEMBROLIZUMAB KEYTRUDA VIAL    
PEMETREXED DISODIUM ALIMTA VIAL    
PENTOSTATIN NIPENT VIAL    
PERTUZUMAB PERJETA VIAL    
POMALIDOMIDE POMALYST CAPSULE    
PRALATREXATE FOLOTYN VIAL    
PROCARBAZINE HCL MATULANE CAPSULE    
RAMUCIRUMAB CYRAMZA VIAL    
RIBOCICLIB SUCCINATE/LETROZOLE KISQALI FEMARA CO-PACK TABLET    
ROMIDEPSIN ISTODAX VIAL    
RUXOLITINIB PHOSPHATE JAKAFI TABLET    
SILTUXIMAB SYLVANT VIAL    
SIPULEUCEL-T/LACTATED RINGERS PROVENGE PLAST. BAG    
SONIDEGIB PHOSPHATE ODOMZO CAPSULE    
STREPTOZOCIN ZANOSAR VIAL    
TALIMOGENE LAHERPAREPVEC IMLYGIC VIAL    
TAMOXIFEN CITRATE SOLTAMOX SOLUTION    
TAMOXIFEN CITRATE TAMOXIFEN CITRATE TABLET    
TEMOZOLOMIDE TEMOZOLOMIDE CAPSULE    
TEMOZOLOMIDE TEMODAR CAPSULE    
TEMOZOLOMIDE TEMODAR VIAL    
TEMSIROLIMUS TORISEL VIAL    
TENIPOSIDE TENIPOSIDE AMPUL    
THIOTEPA THIOTEPA VIAL    
TOPOTECAN HCL HYCAMTIN CAPSULE    
TOPOTECAN HCL TOPOTECAN HCL VIAL    
TOPOTECAN HCL HYCAMTIN VIAL    
TOREMIFENE CITRATE FARESTON TABLET    
TRABECTEDIN YONDELIS VIAL    
TRAMETINIB DIMETHYL SULFOXIDE MEKINIST TABLET    
TRASTUZUMAB HERCEPTIN VIAL    
TRETINOIN TRETINOIN CAPSULE    
VALRUBICIN VALSTAR VIAL    
VENETOCLAX VENCLEXTA STARTING PACK TAB DS PK    
VENETOCLAX VENCLEXTA TABLET    
VINBLASTINE SULFATE VINBLASTINE SULFATE VIAL    
VINCRISTINE SULFATE VINCASAR PFS VIAL    
VINCRISTINE SULFATE VINCRISTINE SULFATE VIAL    
VINCRISTINE SULFATE LIPOSOMAL MARQIBO KIT    
VINORELBINE TARTRATE VINORELBINE TARTRATE VIAL    
VINORELBINE TARTRATE NAVELBINE VIAL    
VISMODEGIB ERIVEDGE CAPSULE    
VORINOSTAT ZOLINZA CAPSULE    
ZIV-AFLIBERCEPT ZALTRAP VIAL