Antineoplastics, Newer

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Drug Use Review Documents

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.
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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
abemaciclib VERZENIO TABLET Medical & Pharmacy PA  
abiraterone acet,submicronized YONSA TABLET Medical & Pharmacy PA  
abiraterone acetate ZYTIGA TABLET Medical & Pharmacy PA  
abiraterone acetate ABIRTEGA TABLET Medical & Pharmacy PA  
abiraterone acetate ABIRATERONE ACETATE TABLET Medical & Pharmacy PA  
acalabrutinib maleate CALQUENCE TABLET Medical & Pharmacy PA  
adagrasib KRAZATI TABLET Medical & Pharmacy PA  
ado-trastuzumab emtansine KADCYLA VIAL Medical & Pharmacy PA  
afamitresgene autoleucel TECELRA PLAST. BAG Medical & Pharmacy PA  
afatinib dimaleate GILOTRIF TABLET Medical & Pharmacy PA  
alectinib HCl ALECENSA CAPSULE Medical & Pharmacy PA  
alpelisib PIQRAY TABLET Medical & Pharmacy PA  
amivantamab-hyaluronidase-lpuj RYBREVANT FASPRO VIAL Medical & Pharmacy PA  
amivantamab-vmjw RYBREVANT VIAL Medical & Pharmacy PA  
apalutamide ERLEADA TABLET Medical & Pharmacy PA  
asciminib hydrochloride SCEMBLIX TABLET Medical & Pharmacy PA  
asparaginase Erwinia-rywn RYLAZE VIAL Medical & Pharmacy PA  
atezolizumab TECENTRIQ VIAL Medical & Pharmacy PA  
atezolizumab-hyaluronidas-tqjs TECENTRIQ HYBREZA VIAL Medical & Pharmacy PA  
avapritinib AYVAKIT TABLET Medical & Pharmacy PA  
avelumab BAVENCIO VIAL Medical & Pharmacy PA  
avutometinib potassium AVMAPKI CAPSULE Medical & Pharmacy PA  
avutometinib/defactinib AVMAPKI-FAKZYNJA COMBO. PKG Medical & Pharmacy PA  
axicabtagene ciloleucel YESCARTA PLAST. BAG Medical & Pharmacy PA  
axitinib INLYTA TABLET Medical & Pharmacy PA  
azacitidine ONUREG TABLET Medical & Pharmacy PA  
belantamab mafodotin-blmf BLENREP VIAL Medical & Pharmacy PA  
belinostat BELEODAQ VIAL Medical & Pharmacy PA  
belzutifan WELIREG TABLET Medical & Pharmacy PA  
bendamustine HCl BELRAPZO VIAL Medical & Pharmacy PA  
bendamustine HCl BENDAMUSTINE HCL VIAL Medical & Pharmacy PA  
bendamustine HCl BENDEKA VIAL Medical & Pharmacy PA  
bendamustine HCl TREANDA VIAL Medical & Pharmacy PA  
bendamustine HCl VIVIMUSTA VIAL Medical & Pharmacy PA  
binimetinib MEKTOVI TABLET Medical & Pharmacy PA  
blinatumomab BLINCYTO KIT Medical & Pharmacy PA  
blinatumomab BLINCYTO VIAL Medical & Pharmacy PA  
bosutinib BOSULIF CAPSULE Medical & Pharmacy PA  
bosutinib BOSUTINIB TABLET Medical & Pharmacy PA  
bosutinib BOSULIF TABLET Medical & Pharmacy PA  
brentuximab vedotin ADCETRIS VIAL Medical & Pharmacy PA  
brexucabtagene autoleucel TECARTUS PLAST. BAG Medical & Pharmacy PA  
brigatinib ALUNBRIG TAB DS PK Medical & Pharmacy PA  
brigatinib ALUNBRIG TABLET Medical & Pharmacy PA  
cabazitaxel JEVTANA VIAL Medical & Pharmacy PA  
cabozantinib s-malate COMETRIQ CAPSULE Medical & Pharmacy PA  
cabozantinib s-malate CABOMETYX TABLET Medical & Pharmacy PA  
calaspargase pegol-mknl ASPARLAS VIAL Medical & Pharmacy PA  
capivasertib TRUQAP TABLET Medical & Pharmacy PA  
capmatinib hydrochloride TABRECTA TABLET Medical & Pharmacy PA  
carfilzomib KYPROLIS VIAL Medical & Pharmacy PA  
cemiplimab-rwlc LIBTAYO VIAL Medical & Pharmacy PA  
ceritinib ZYKADIA TABLET Medical & Pharmacy PA  
ciltacabtagene autoleucel CARVYKTI PLAST. BAG Medical & Pharmacy PA  
cobimetinib fumarate COTELLIC TABLET Medical & Pharmacy PA  
cosibelimab-ipdl UNLOXCYT VIAL Medical & Pharmacy PA  
crizotinib XALKORI CAPSULE Medical & Pharmacy PA  
crizotinib XALKORI PEL DSP CP Medical & Pharmacy PA  
dabrafenib mesylate TAFINLAR CAPSULE Medical & Pharmacy PA  
dabrafenib mesylate TAFINLAR TAB SUSP Medical & Pharmacy PA  
dacomitinib VIZIMPRO TABLET Medical & Pharmacy PA  
daratumumab DARZALEX VIAL Medical & Pharmacy PA  
daratumumab-hyaluronidase-fihj DARZALEX FASPRO VIAL Medical & Pharmacy PA  
darolutamide NUBEQA TABLET Medical & Pharmacy PA  
dasatinib anhydrous PHYRAGO TABLET Medical & Pharmacy PA  
datopotamab deruxtecan-dlnk DATROWAY VIAL Medical & Pharmacy PA  
decitabine/cedazuridine INQOVI TABLET Medical & Pharmacy PA  
defactinib hydrochloride FAKZYNJA TABLET Medical & Pharmacy PA  
degarelix acetate FIRMAGON VIAL Medical & Pharmacy PA  
denileukin diftitox-cxdl LYMPHIR VIAL Medical & Pharmacy PA  
dinutuximab UNITUXIN VIAL Medical & Pharmacy PA  
docetaxel/albumin, human BEIZRAY VIAL Medical & Pharmacy PA  
docetaxel/albumin, human BEIZRAY-ALBUMIN VIAL Medical & Pharmacy PA  
dordaviprone HCl MODEYSO CAPSULE Medical & Pharmacy PA  
dostarlimab-gxly JEMPERLI VIAL Medical & Pharmacy PA  
durvalumab IMFINZI VIAL Medical & Pharmacy PA  
duvelisib COPIKTRA CAPSULE Medical & Pharmacy PA  
eflornithine HCl IWILFIN TABLET Medical & Pharmacy PA  
elacestrant HCl ORSERDU TABLET Medical & Pharmacy PA  
elotuzumab EMPLICITI VIAL Medical & Pharmacy PA  
elranatamab-bcmm ELREXFIO VIAL Medical & Pharmacy PA  
enasidenib mesylate IDHIFA TABLET Medical & Pharmacy PA  
encorafenib BRAFTOVI CAPSULE Medical & Pharmacy PA  
enfortumab vedotin-ejfv PADCEV VIAL Medical & Pharmacy PA  
ensartinib hydrochloride ENSACOVE CAPSULE Medical & Pharmacy PA  
entrectinib ROZLYTREK CAPSULE Medical & Pharmacy PA  
entrectinib ROZLYTREK PELET PACK Medical & Pharmacy PA  
enzalutamide XTANDI CAPSULE Medical & Pharmacy PA  
enzalutamide XTANDI TABLET Medical & Pharmacy PA  
epcoritamab-bysp EPKINLY VIAL Medical & Pharmacy PA  
erdafitinib BALVERSA TABLET Medical & Pharmacy PA  
eribulin mesylate ERIBULIN MESYLATE VIAL Medical & Pharmacy PA  
eribulin mesylate HALAVEN VIAL Medical & Pharmacy PA  
everolimus AFINITOR DISPERZ TAB SUSP Medical & Pharmacy PA  
everolimus EVEROLIMUS TAB SUSP Medical & Pharmacy PA  
everolimus YULITHIRA TABLET Medical & Pharmacy PA  
everolimus AFINITOR TABLET Medical & Pharmacy PA  
everolimus TORPENZ TABLET Medical & Pharmacy PA  
everolimus EVEROLIMUS TABLET Medical & Pharmacy PA  
fam-trastuzumab deruxtecn-nxki ENHERTU VIAL Medical & Pharmacy PA  
fedratinib dihydrochloride INREBIC CAPSULE Medical & Pharmacy PA  
fruquintinib FRUZAQLA CAPSULE Medical & Pharmacy PA  
futibatinib LYTGOBI TABLET Medical & Pharmacy PA  
gilteritinib fumarate XOSPATA TABLET Medical & Pharmacy PA  
glasdegib maleate DAURISMO TABLET Medical & Pharmacy PA  
glofitamab-gxbm COLUMVI VIAL Medical & Pharmacy PA  
iberdomide HCl ZENBEXUS CAPSULE Medical & Pharmacy PA  
ibrutinib IMBRUVICA CAPSULE Medical & Pharmacy PA  
ibrutinib IMBRUVICA ORAL SUSP Medical & Pharmacy PA  
ibrutinib IMBRUVICA TABLET Medical & Pharmacy PA  
idecabtagene vicleucel ABECMA PLAST. BAG Medical & Pharmacy PA  
idelalisib ZYDELIG TABLET Medical & Pharmacy PA  
imetelstat sodium RYTELO VIAL Medical & Pharmacy PA  
imlunestrant tosylate INLURIYO TABLET Medical & Pharmacy PA  
inavolisib ITOVEBI TABLET Medical & Pharmacy PA  
inotuzumab ozogamicin BESPONSA VIAL Medical & Pharmacy PA  
ipilimumab YERVOY VIAL Medical & Pharmacy PA  
isatuximab-irfc SARCLISA VIAL Medical & Pharmacy PA  
isatuximab-irfc SARCLISA ESCENA VIAL Medical & Pharmacy PA  
ivosidenib TIBSOVO TABLET Medical & Pharmacy PA  
ixazomib citrate NINLARO CAPSULE Medical & Pharmacy PA  
larotrectinib sulfate VITRAKVI CAPSULE Medical & Pharmacy PA  
larotrectinib sulfate VITRAKVI SOLUTION Medical & Pharmacy PA  
lazertinib mesylate LAZCLUZE TABLET Medical & Pharmacy PA  
lenvatinib mesylate LENVIMA CAPSULE Medical & Pharmacy PA  
linvoseltamab-gcpt LYNOZYFIC VIAL Medical & Pharmacy PA  
lisocabtagene maraleucel BREYANZI VIAL Medical & Pharmacy PA  
lisocabtagene maraleucel,1 of2 BREYANZI CD8 COMPONENT VIAL Medical & Pharmacy PA  
lisocabtagene maraleucel,2 of2 BREYANZI CD4 COMPONENT VIAL Medical & Pharmacy PA  
loncastuximab tesirine-lpyl ZYNLONTA VIAL Medical & Pharmacy PA  
lorlatinib LORBRENA TABLET Medical & Pharmacy PA  
lurbinectedin ZEPZELCA VIAL Medical & Pharmacy PA  
lutetium Lu 177 dotatate LUTATHERA VIAL Medical & Pharmacy PA  
melphalan HCl HEPZATO VIAL Medical & Pharmacy PA  
midostaurin RYDAPT CAPSULE Medical & Pharmacy PA  
mirdametinib GOMEKLI CAPSULE    
mirdametinib GOMEKLI TAB SUSP    
mirvetuximab soravtansine-gynx ELAHERE VIAL Medical & Pharmacy PA  
mogamulizumab-kpkc POTELIGEO VIAL Medical & Pharmacy PA  
momelotinib dihydrochloride OJJAARA TABLET Medical & Pharmacy PA  
mosunetuzumab-axgb LUNSUMIO VELO VIAL Medical & Pharmacy PA  
mosunetuzumab-axgb LUNSUMIO VIAL Medical & Pharmacy PA  
nadofaragene firadenovec-vncg ADSTILADRIN VIAL Medical & Pharmacy PA  
naxitamab-gqgk DANYELZA VIAL Medical & Pharmacy PA  
neratinib maleate NERLYNX TABLET Medical & Pharmacy PA  
nilotinib CAVHANZA TAB RAPDIS Medical & Pharmacy PA  
nilotinib d-tartrate NILOTINIB D-TARTRATE CAPSULE Medical & Pharmacy PA  
nilotinib tartrate DANZITEN TABLET Medical & Pharmacy PA  
niraparib tosylate ZEJULA TABLET Medical & Pharmacy PA  
niraparib/abiraterone AKEEGA TABLET Medical & Pharmacy PA  
nirogacestat hydrobromide OGSIVEO TABLET Medical & Pharmacy PA  
nivolumab OPDIVO VIAL Medical & Pharmacy PA  
nivolumab-hyaluronidase-nvhy OPDIVO QVANTIG VIAL Medical & Pharmacy PA  
nivolumab-relatlimab-rmbw OPDUALAG VIAL Medical & Pharmacy PA  
nogapendekin alfa inbakic-pmln ANKTIVA VIAL Medical & Pharmacy PA  
obecabtagene autoleucel AUCATZYL PLAST. BAG Medical & Pharmacy PA  
obinutuzumab GAZYVA VIAL Medical & Pharmacy PA  
ofatumumab ARZERRA VIAL Medical & Pharmacy PA  
olaparib LYNPARZA TABLET Medical & Pharmacy PA  
olutasidenib REZLIDHIA CAPSULE Medical & Pharmacy PA  
omidubicel-onlv OMISIRGE PLAST. BAG Medical & Pharmacy PA  
osimertinib mesylate TAGRISSO TABLET Medical & Pharmacy PA  
pacritinib citrate VONJO CAPSULE Medical & Pharmacy PA  
palbociclib IBRANCE CAPSULE Medical & Pharmacy PA  
palbociclib IBRANCE TABLET Medical & Pharmacy PA  
pazopanib HCl PAZOPANIB HCL TABLET Medical & Pharmacy PA  
pazopanib HCl VOTRIENT TABLET Medical & Pharmacy PA  
pembrolizum-berahyaluron-pmph KEYTRUDA QLEX VIAL Medical & Pharmacy PA  
pembrolizumab KEYTRUDA VIAL Medical & Pharmacy PA  
pemetrexed PEMETREXED VIAL Medical & Pharmacy PA  
pemetrexed PEMFEXY VIAL Medical & Pharmacy PA  
pemetrexed dipotassium AXTLE VIAL Medical & Pharmacy PA  
pemigatinib PEMAZYRE TABLET Medical & Pharmacy PA  
pertuzumab PERJETA VIAL Medical & Pharmacy PA  
pertuzumab-trastuzumab-hy-zzxf PHESGO VIAL Medical & Pharmacy PA  
pexidartinib hydrochloride TURALIO CAPSULE Medical & Pharmacy PA  
pirtobrutinib JAYPIRCA TABLET Medical & Pharmacy PA  
pivekimab sunirine-pvzy DECNUPAZ VIAL Medical & Pharmacy PA  
polatuzumab vedotin-piiq POLIVY VIAL Medical & Pharmacy PA  
pomalidomide POMALIDOMIDE CAPSULE Medical & Pharmacy PA  
pomalidomide POMALYST CAPSULE Medical & Pharmacy PA  
ponatinib HCl ICLUSIG TABLET Medical & Pharmacy PA  
pralatrexate FOLOTYN VIAL Medical & Pharmacy PA  
pralatrexate PRALATREXATE VIAL Medical & Pharmacy PA  
pralsetinib GAVRETO CAPSULE Medical & Pharmacy PA  
quizartinib dihydrochloride VANFLYTA TABLET Medical & Pharmacy PA  
ramucirumab CYRAMZA VIAL Medical & Pharmacy PA  
regorafenib STIVARGA TABLET Medical & Pharmacy PA  
relacorilant LIFYORLI CAPSULE Medical & Pharmacy PA  
relugolix ORGOVYX TABLET Medical & Pharmacy PA  
repotrectinib AUGTYRO CAPSULE Medical & Pharmacy PA  
retifanlimab-dlwr ZYNYZ VIAL Medical & Pharmacy PA  
revumenib citrate REVUFORJ TABLET Medical & Pharmacy PA  
ribociclib succinate KISQALI TABLET Medical & Pharmacy PA  
ripretinib QINLOCK TABLET Medical & Pharmacy PA  
romidepsin ISTODAX VIAL Medical & Pharmacy PA  
romidepsin ROMIDEPSIN VIAL Medical & Pharmacy PA  
ropeginterferon alfa-2b-njft BESREMI PEN PEN INJCTR Medical & Pharmacy PA  
ropeginterferon alfa-2b-njft BESREMI SYRINGE Medical & Pharmacy PA  
rucaparib camsylate RUBRACA TABLET Medical & Pharmacy PA  
ruxolitinib phosphate JAKAFI XR TAB ER 24H Medical & Pharmacy PA  
ruxolitinib phosphate JAKAFI TABLET Medical & Pharmacy PA  
sacituzumab govitecan-hziy TRODELVY VIAL Medical & Pharmacy PA  
selinexor XPOVIO TABLET Medical & Pharmacy PA  
selpercatinib RETEVMO CAPSULE Medical & Pharmacy PA  
selpercatinib RETEVMO TABLET Medical & Pharmacy PA  
selumetinib sulfate KOSELUGO CAP SPRINK Medical & Pharmacy PA  
selumetinib sulfate KOSELUGO CAPSULE Medical & Pharmacy PA  
sevabertinib HYRNUO TABLET Medical & Pharmacy PA  
siltuximab SYLVANT VIAL Medical & Pharmacy PA  
sipuleucel-T/lactated ringers PROVENGE PLAST. BAG Medical & Pharmacy PA  
sirolimus protein-bound FYARRO VIAL Medical & Pharmacy PA  
sonidegib phosphate ODOMZO CAPSULE Medical & Pharmacy PA  
sotorasib LUMAKRAS TABLET Medical & Pharmacy PA  
tafasitamab-cxix MONJUVI VIAL Medical & Pharmacy PA  
tagraxofusp-erzs ELZONRIS VIAL Medical & Pharmacy PA BILL FFS  
talazoparib tosylate TALZENNA CAPSULE Medical & Pharmacy PA  
taletrectinib adipate IBTROZI CAPSULE Medical & Pharmacy PA  
talimogene laherparepvec IMLYGIC VIAL Medical & Pharmacy PA  
talquetamab-tgvs TALVEY VIAL Medical & Pharmacy PA  
tarlatamab-dlle IMDELLTRA VIAL Medical & Pharmacy PA  
tebentafusp-tebn KIMMTRAK VIAL Medical & Pharmacy PA  
teclistamab-cqyv TECVAYLI VIAL Medical & Pharmacy PA  
telisotuzumab vedotin-tllv EMRELIS VIAL Medical & Pharmacy PA  
tepotinib HCl TEPMETKO TABLET Medical & Pharmacy PA  
tisagenlecleucel KYMRIAH PLAST. BAG Medical & Pharmacy PA  
tislelizumab-jsgr TEVIMBRA VIAL Medical & Pharmacy PA  
tisotumab vedotin-tftv TIVDAK VIAL Medical & Pharmacy PA  
tivozanib HCl FOTIVDA CAPSULE Medical & Pharmacy PA  
toripalimab-tpzi LOQTORZI VIAL Medical & Pharmacy PA  
tovorafenib OJEMDA SUSP RECON Medical & Pharmacy PA  
tovorafenib OJEMDA TABLET Medical & Pharmacy PA  
trabectedin YONDELIS VIAL Medical & Pharmacy PA  
trabectedin EVDI VIAL Medical & Pharmacy PA  
trametinib dimethyl sulfoxide MEKINIST SOLN RECON Medical & Pharmacy PA  
trametinib dimethyl sulfoxide MEKINIST TABLET Medical & Pharmacy PA  
trastuzumab-anns KANJINTI VIAL Medical & Pharmacy PA  
trastuzumab-dkst OGIVRI VIAL Medical & Pharmacy PA  
trastuzumab-dttb ONTRUZANT VIAL Medical & Pharmacy PA  
trastuzumab-hyaluronidase-oysk HERCEPTIN HYLECTA VIAL Medical & Pharmacy PA  
trastuzumab-pkrb HERZUMA VIAL Medical & Pharmacy PA  
trastuzumab-qyyp TRAZIMERA VIAL Medical & Pharmacy PA  
trastuzumab-strf HERCESSI VIAL Medical & Pharmacy PA  
tremelimumab-actl IMJUDO VIAL Medical & Pharmacy PA  
treosulfan GRAFAPEX VIAL Medical & Pharmacy PA  
trifluridine/tipiracil HCl LONSURF TABLET Medical & Pharmacy PA  
tucatinib TUKYSA TABLET Medical & Pharmacy PA  
vandetanib CAPRELSA TABLET Medical & Pharmacy PA  
vemurafenib ZELBORAF TABLET Medical & Pharmacy PA  
venetoclax VENCLEXTA STARTING PACK TAB DS PK Medical & Pharmacy PA  
venetoclax VENCLEXTA TABLET Medical & Pharmacy PA  
vimseltinib ROMVIMZA CAPSULE Medical & Pharmacy PA  
vismodegib ERIVEDGE CAPSULE Medical & Pharmacy PA  
vorasidenib citrate VORANIGO TABLET Medical & Pharmacy PA  
zanidatamab-hrii ZIIHERA VIAL Medical & Pharmacy PA  
zanubrutinib BRUKINSA CAPSULE Medical & Pharmacy PA  
zanubrutinib BRUKINSA TABLET Medical & Pharmacy PA  
zenocutuzumab-zbco BIZENGRI VIAL Medical & Pharmacy PA  
zidesamtinib JIDEYTRO TABLET Medical & Pharmacy PA  
ziftomenib KOMZIFTI CAPSULE Medical & Pharmacy PA  
ziv-aflibercept ZALTRAP VIAL Medical & Pharmacy PA  
zolbetuximab-clzb VYLOY VIAL Medical & Pharmacy PA  
zongertinib HERNEXEOS TABLET Medical & Pharmacy PA