Antineoplastics, Older

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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.
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
mitoxantrone HCl MITOXANTRONE HCL VIAL N   N  
alemtuzumab CAMPATH VIAL   N  
anastrozole ANASTROZOLE TABLET   N  
anastrozole ARIMIDEX TABLET   N  
arsenic trioxide ARSENIC TRIOXIDE VIAL   N  
arsenic trioxide TRISENOX VIAL   N  
azacitidine AZACITIDINE VIAL   N  
azacitidine VIDAZA VIAL   N  
BCG live BCG (TICE STRAIN) VIAL   N  
bevacizumab-adcd VEGZELMA VIAL   N  
bevacizumab-awwb MVASI VIAL   N  
bevacizumab-bvzr ZIRABEV VIAL   N  
bevacizumab-maly ALYMSYS VIAL   N  
bevacizumab-nwgd JOBEVNE VIAL   N  
bexarotene BEXAROTENE CAPSULE   N  
bexarotene BEXAROTENE GEL (GRAM)   N  
bicalutamide CASODEX TABLET   N  
bicalutamide BICALUTAMIDE TABLET   N  
bleomycin sulfate BLEOMYCIN SULFATE VIAL   N  
bortezomib BORUZU VIAL   N  
bortezomib VELCADE VIAL   N  
bortezomib BORTEZOMIB VIAL   N  
busulfan BUSULFEX VIAL   N  
busulfan BUSULFAN VIAL   N  
capecitabine XELODA TABLET   N  
capecitabine CAPECITABINE TABLET   N  
carboplatin PARAPLATIN VIAL   N  
carboplatin KYXATA VIAL   N  
carboplatin CARBOPLATIN VIAL   N  
carmustine BICNU VIAL   N  
carmustine CARMUSTINE VIAL   N  
carmustine in polifeprosan 20 GLIADEL WAFER   N  
cetuximab ERBITUX VIAL   N  
cisplatin KEMOPLAT VIAL   N  
cisplatin CISPLATIN VIAL   N  
cladribine CLADRIBINE VIAL   N  
clofarabine CLOFARABINE VIAL   N  
cyclophosphamide CYCLOPHOSPHAMIDE CAPSULE   N  
cyclophosphamide CYCLOPHOSPHAMIDE TABLET   N  
cyclophosphamide CYCLOPHOSPHAMIDE VIAL   N  
cyclophosphamide FRINDOVYX VIAL   N  
cyclophosphamide NEOSAR VIAL   N  
cytarabine CYTARABINE VIAL   N  
cytarabine/PF CYTARABINE VIAL   N  
dacarbazine DACARBAZINE VIAL   N  
dactinomycin DACTINOMYCIN VIAL   N  
dasatinib PHYRAGO TABLET   N  
dasatinib DASATINIB TABLET   N  
dasatinib SPRYCEL TABLET   N  
daunorubicin HCl DAUNORUBICIN HCL VIAL   N  
daunorubicin/cytarabine lipos VYXEOS VIAL   N  
decitabine DECITABINE VIAL   N  
docetaxel DOCIVYX VIAL   N  
docetaxel DOCETAXEL VIAL   N  
doxorubicin HCl DOXORUBICIN HCL VIAL   N  
doxorubicin HCl ADRIAMYCIN VIAL   N  
doxorubicin HCl ADRIAMYCIN RDF VIAL   N  
doxorubicin HCl peg-liposomal DOXORUBICIN HCL LIPOSOME VIAL   N  
doxorubicin HCl peg-liposomal DOXIL VIAL   N  
doxorubicin HCl peg-liposomal CAELYX VIAL   N  
epirubicin HCl EPIRUBICIN HCL VIAL   N  
epirubicin HCl ELLENCE VIAL   N  
erlotinib HCl ERLOTINIB HCL TABLET   N  
etoposide ETOPOSIDE CAPSULE   N  
etoposide ETOPOSIDE VIAL   N  
etoposide phosphate ETOPOPHOS VIAL   N  
exemestane AROMASIN TABLET   N  
exemestane EXEMESTANE TABLET   N  
fludarabine phosphate FLUDARABINE PHOSPHATE VIAL   N  
fluorouracil FLUOROURACIL VIAL   N  
flutamide FLUTAMIDE CAPSULE   N  
fulvestrant FASLODEX SYRINGE   N  
fulvestrant FULVESTRANT SYRINGE   N  
gefitinib GEFITINIB TABLET   N  
gefitinib IRESSA TABLET   N  
gemcitabine HCl INLEXZO IMPLANT   N  
gemcitabine HCl AVGEMSI VIAL   N  
gemcitabine HCl GEMCITABINE HCL VIAL   N  
gemtuzumab ozogamicin MYLOTARG VIAL   N  
idarubicin HCl IDARUBICIN HCL VIAL   N  
idarubicin HCl IDAMYCIN PFS VIAL   N  
ifosfamide IFOSFAMIDE VIAL   N  
ifosfamide IFEX VIAL   N  
imatinib mesylate IMKELDI SOLUTION   N  
imatinib mesylate IMATINIB MESYLATE TABLET   N  
imatinib mesylate GLEEVEC TABLET   N  
imlunestrant tosylate INLURIYO TABLET   N  
interferon gamma-1b,recomb. ACTIMMUNE VIAL   N  
irinotecan HCl IRINOTECAN HCL VIAL   N  
irinotecan HCl CAMPTOSAR VIAL   N  
irinotecan liposomal ONIVYDE VIAL   N  
ixabepilone IXEMPRA VIAL   N  
kit Y-90/ibritumomab/h.albumin ZEVALIN KIT   N  
lapatinib ditosylate LAPATINIB TABLET   N  
lapatinib ditosylate TYKERB TABLET   N  
lenalidomide LENALIDOMIDE CAPSULE   N  
lenalidomide REVLIMID CAPSULE   N  
letrozole FEMARA TABLET   N  
letrozole LETROZOLE TABLET   N  
lomustine LOMUSTINE CAPSULE   N  
mechlorethamine HCl VALCHLOR GEL (GRAM)   N  
megestrol acetate MEGESTROL ACETATE TABLET   N  
melphalan HCl IVRA VIAL   N  
melphalan HCl MELPHALAN HCL VIAL   N  
melphalan HCl/betadex sbes EVOMELA VIAL   N  
mercaptopurine MERCAPTOPURINE ORAL SUSP   N  
mercaptopurine PURIXAN ORAL SUSP   N  
mercaptopurine MERCAPTOPURINE TABLET   N  
methotrexate XATMEP SOLUTION   N  
methotrexate JYLAMVO SOLUTION   N  
methotrexate sodium TREXALL TABLET   N  
methotrexate sodium METHOTREXATE TABLET   N  
methotrexate sodium METHOTREXATE VIAL   N  
methotrexate sodium/PF METHOTREXATE SODIUM VIAL   N  
methotrexate sodium/PF METHOTREXATE VIAL   N  
mitomycin JELMYTO KIT   N  
mitomycin ZUSDURI KIT   N  
mitomycin MITOMYCIN VIAL   N  
mitotane LYSODREN TABLET   N  
nelarabine NELARABINE VIAL   N  
nelarabine ARRANON VIAL   N  
nilotinib HCl NILOTINIB HCL CAPSULE   N  
nilotinib HCl TASIGNA CAPSULE   N  
nilutamide NILUTAMIDE TABLET   N  
nogapendekin alfa inbakic-pmln ANKTIVA VIAL   N  
oxaliplatin OXALIPLATIN VIAL   N  
paclitaxel PACLITAXEL VIAL   N  
paclitaxel protein-bound ABRAXANE VIAL   N  
paclitaxel protein-bound PACLITAXEL PROTEIN-BOUND VIAL   N  
panitumumab VECTIBIX VIAL   N  
pegaspargase ONCASPAR VIAL   N  
pemetrexed disodium PEMRYDI RTU VIAL   N  
pemetrexed disodium ALIMTA VIAL   N  
pemetrexed disodium PEMETREXED DISODIUM VIAL   N  
pentostatin NIPENT VIAL   N  
plicamycin MITHRACIN VIAL   N  
procarbazine HCl MATULANE CAPSULE   N  
rituximab/hyaluronidase,human RITUXAN HYCELA VIAL   N  
sorafenib tosylate NEXAVAR TABLET   N  
sorafenib tosylate SORAFENIB TABLET   N  
sunitinib malate SUNITINIB MALATE CAPSULE   N  
sunitinib malate SUTENT CAPSULE   N  
tamoxifen citrate SOLTAMOX SOLUTION   N  
tamoxifen citrate TAMOXIFEN CITRATE TABLET   N  
temozolomide TEMOZOLOMIDE CAPSULE   N  
temozolomide TEMODAR VIAL   N  
temsirolimus TORISEL VIAL   N  
temsirolimus TEMSIROLIMUS VIAL   N  
thiotepa TEPADINA PLAST. BAG   N  
thiotepa TEPYLUTE VIAL   N  
thiotepa THIOTEPA VIAL   N  
thiotepa TEPADINA VIAL   N  
topotecan HCl HYCAMTIN CAPSULE   N  
topotecan HCl TOPOTECAN HCL VIAL   N  
toremifene citrate FARESTON TABLET   N  
toremifene citrate TOREMIFENE CITRATE TABLET   N  
trastuzumab HERCEPTIN VIAL   N  
tretinoin TRETINOIN CAPSULE   N  
valrubicin VALSTAR VIAL   N  
valrubicin VALRUBICIN VIAL   N  
vinblastine sulfate VINBLASTINE SULFATE VIAL   N  
vincristine sulfate VINCRISTINE SULFATE VIAL   N  
vincristine sulfate VINCASAR PFS VIAL   N  
vinorelbine tartrate VINORELBINE TARTRATE VIAL   N  
vorinostat ZOLINZA CAPSULE   N  
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