Antineoplastics, Newer

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PDL Reference 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.

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