Antineoplastics, Newer
PDL Reference Documents
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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| abiraterone acet,submicronized | YONSA | TABLET | Pharmacy PA | N | ||
| abiraterone acetate | ABIRTEGA | TABLET | Pharmacy PA | N | ||
| acalabrutinib maleate | CALQUENCE | TABLET | Pharmacy PA | N | ||
| afatinib dimaleate | GILOTRIF | TABLET | Pharmacy PA | N | ||
| alpelisib | PIQRAY | TABLET | Pharmacy PA | N | ||
| apalutamide | ERLEADA | TABLET | Pharmacy PA | N | ||
| asparaginase Erwinia-rywn | RYLAZE | VIAL | Pharmacy PA | N | ||
| atezolizumab-hyaluronidas-tqjs | TECENTRIQ HYBREZA | VIAL | Pharmacy PA | N | ||
| avelumab | BAVENCIO | VIAL | Pharmacy PA | N | ||
| axitinib | INLYTA | TABLET | Pharmacy PA | N | ||
| belinostat | BELEODAQ | VIAL | Pharmacy PA | N | ||
| bendamustine HCl | VIVIMUSTA | VIAL | Pharmacy PA | N | ||
| bendamustine HCl | BENDEKA | VIAL | Pharmacy PA | N | ||
| bendamustine HCl | BELRAPZO | VIAL | Pharmacy PA | N | ||
| binimetinib | MEKTOVI | TABLET | Pharmacy PA | N | ||
| blinatumomab | BLINCYTO | KIT | Pharmacy PA | N | ||
| blinatumomab | BLINCYTO | VIAL | Pharmacy PA | N | ||
| bosutinib | BOSULIF | CAPSULE | Pharmacy PA | N | ||
| brentuximab vedotin | ADCETRIS | VIAL | Pharmacy PA | N | ||
| brigatinib | ALUNBRIG | TAB DS PK | Pharmacy PA | N | ||
| cabazitaxel | JEVTANA | VIAL | Pharmacy PA | N | ||
| cabozantinib s-malate | COMETRIQ | CAPSULE | Pharmacy PA | N | ||
| calaspargase pegol-mknl | ASPARLAS | VIAL | Pharmacy PA | N | ||
| carfilzomib | KYPROLIS | VIAL | Pharmacy PA | N | ||
| ceritinib | ZYKADIA | TABLET | Pharmacy PA | N | ||
| cobimetinib fumarate | COTELLIC | TABLET | Pharmacy PA | N | ||
| crizotinib | XALKORI | PEL DSP CP | Pharmacy PA | N | ||
| dabrafenib mesylate | TAFINLAR | TAB SUSP | Pharmacy PA | N | ||
| decitabine/cedazuridine | INQOVI | TABLET | Pharmacy PA | N | ||
| degarelix acetate | FIRMAGON | VIAL | Pharmacy PA | N | ||
| docetaxel/albumin, human | BEIZRAY | VIAL | Pharmacy PA | N | ||
| dordaviprone HCl | MODEYSO | CAPSULE | Pharmacy PA | N | ||
| durvalumab | IMFINZI | VIAL | Pharmacy PA | N | ||
| elotuzumab | EMPLICITI | VIAL | Pharmacy PA | N | ||
| enasidenib mesylate | IDHIFA | TABLET | Pharmacy PA | N | ||
| enfortumab vedotin-ejfv | PADCEV | VIAL | Pharmacy PA | N | ||
| entrectinib | ROZLYTREK | PELET PACK | Pharmacy PA | N | ||
| enzalutamide | XTANDI | CAPSULE | Pharmacy PA | N | ||
| enzalutamide | XTANDI | TABLET | Pharmacy PA | N | ||
| everolimus | AFINITOR DISPERZ | TAB SUSP | Pharmacy PA | N | ||
| fam-trastuzumab deruxtecn-nxki | ENHERTU | VIAL | Pharmacy PA | N | ||
| fruquintinib | FRUZAQLA | CAPSULE | Pharmacy PA | N | ||
| gilteritinib fumarate | XOSPATA | TABLET | Pharmacy PA | N | ||
| glofitamab-gxbm | COLUMVI | VIAL | Pharmacy PA | N | ||
| ibrutinib | IMBRUVICA | CAPSULE | Pharmacy PA | N | ||
| ibrutinib | IMBRUVICA | ORAL SUSP | Pharmacy PA | N | ||
| idecabtagene vicleucel | ABECMA | PLAST. BAG | Pharmacy PA | N | ||
| imetelstat sodium | RYTELO | VIAL | Pharmacy PA | N | ||
| inotuzumab ozogamicin | BESPONSA | VIAL | Pharmacy PA | N | ||
| isatuximab-irfc | SARCLISA | VIAL | Pharmacy PA | N | ||
| ivosidenib | TIBSOVO | TABLET | Pharmacy PA | N | ||
| larotrectinib sulfate | VITRAKVI | CAPSULE | Pharmacy PA | N | ||
| lazertinib mesylate | LAZCLUZE | TABLET | Pharmacy PA | N | ||
| lisocabtagene maraleucel,1 of2 | BREYANZI CD8 COMPONENT | VIAL | Pharmacy PA | N | ||
| lurbinectedin | ZEPZELCA | VIAL | Pharmacy PA | N | ||
| midostaurin | RYDAPT | CAPSULE | Pharmacy PA | N | ||
| mogamulizumab-kpkc | POTELIGEO | VIAL | Pharmacy PA | N | ||
| mosunetuzumab-axgb | LUNSUMIO | VIAL | Pharmacy PA | N | ||
| naxitamab-gqgk | DANYELZA | VIAL | Pharmacy PA | N | ||
| necitumumab | PORTRAZZA | VIAL | Pharmacy PA | N | ||
| neratinib maleate | NERLYNX | TABLET | Pharmacy PA | N | ||
| nilotinib d-tartrate | NILOTINIB D-TARTRATE | CAPSULE | Pharmacy PA | N | ||
| nilotinib tartrate | DANZITEN | TABLET | Pharmacy PA | N | ||
| niraparib tosylate | ZEJULA | TABLET | Pharmacy PA | N | ||
| nirogacestat hydrobromide | OGSIVEO | TABLET | Pharmacy PA | N | ||
| nivolumab | OPDIVO | VIAL | Pharmacy PA | N | ||
| nivolumab-hyaluronidase-nvhy | OPDIVO QVANTIG | VIAL | Pharmacy PA | N | ||
| nivolumab-relatlimab-rmbw | OPDUALAG | VIAL | Pharmacy PA | N | ||
| obecabtagene autoleucel | AUCATZYL | PLAST. BAG | Pharmacy PA | N | ||
| ofatumumab | ARZERRA | VIAL | Pharmacy PA | N | ||
| olutasidenib | REZLIDHIA | CAPSULE | Pharmacy PA | N | ||
| osimertinib mesylate | TAGRISSO | TABLET | Pharmacy PA | N | ||
| palbociclib | IBRANCE | CAPSULE | Pharmacy PA | N | ||
| palbociclib | IBRANCE | TABLET | Pharmacy PA | N | ||
| pazopanib HCl | PAZOPANIB HCL | TABLET | Pharmacy PA | N | ||
| pembrolizumab | KEYTRUDA | VIAL | Pharmacy PA | N | ||
| pemetrexed | PEMETREXED | VIAL | Pharmacy PA | N | ||
| pemetrexed dipotassium | AXTLE | VIAL | Pharmacy PA | N | ||
| pertuzumab-trastuzumab-hy-zzxf | PHESGO | VIAL | Pharmacy PA | N | ||
| pirtobrutinib | JAYPIRCA | TABLET | Pharmacy PA | N | ||
| ponatinib HCl | ICLUSIG | TABLET | Pharmacy PA | N | ||
| pralatrexate | FOLOTYN | VIAL | Pharmacy PA | N | ||
| relugolix | ORGOVYX | TABLET | Pharmacy PA | N | ||
| retifanlimab-dlwr | ZYNYZ | VIAL | Pharmacy PA | N | ||
| ribociclib succinate/letrozole | KISQALI FEMARA CO-PACK | TABLET | Pharmacy PA | N | ||
| romidepsin | ROMIDEPSIN | VIAL | Pharmacy PA | N | ||
| rucaparib camsylate | RUBRACA | TABLET | Pharmacy PA | N | ||
| ruxolitinib phosphate | JAKAFI | TABLET | Pharmacy PA | N | ||
| selinexor | XPOVIO | TABLET | Pharmacy PA | N | ||
| selpercatinib | RETEVMO | TABLET | Pharmacy PA | N | ||
| selumetinib sulfate | KOSELUGO | CAPSULE | Pharmacy PA | N | ||
| sipuleucel-T/lactated ringers | PROVENGE | PLAST. BAG | Pharmacy PA | N | ||
| sonidegib phosphate | ODOMZO | CAPSULE | Pharmacy PA | N | ||
| sotorasib | LUMAKRAS | TABLET | Pharmacy PA | N | ||
| tafasitamab-cxix | MONJUVI | VIAL | Pharmacy PA | N | ||
| tagraxofusp-erzs | ELZONRIS | VIAL | Pharmacy PA | N | ||
| talazoparib tosylate | TALZENNA | CAPSULE | Pharmacy PA | N | ||
| talimogene laherparepvec | IMLYGIC | VIAL | Pharmacy PA | N | ||
| tarlatamab-dlle | IMDELLTRA | VIAL | Pharmacy PA | N | ||
| tebentafusp-tebn | KIMMTRAK | VIAL | Pharmacy PA | N | ||
| teclistamab-cqyv | TECVAYLI | VIAL | Pharmacy PA | N | ||
| telisotuzumab vedotin-tllv | EMRELIS | VIAL | Pharmacy PA | N | ||
| tislelizumab-jsgr | TEVIMBRA | VIAL | Pharmacy PA | N | ||
| tisotumab vedotin-tftv | TIVDAK | VIAL | Pharmacy PA | N | ||
| toripalimab-tpzi | LOQTORZI | VIAL | Pharmacy PA | N | ||
| tovorafenib | OJEMDA | TABLET | Pharmacy PA | N | ||
| trametinib dimethyl sulfoxide | MEKINIST | SOLN RECON | Pharmacy PA | N | ||
| trametinib dimethyl sulfoxide | MEKINIST | TABLET | Pharmacy PA | N | ||
| trastuzumab-anns | KANJINTI | VIAL | Pharmacy PA | N | ||
| trastuzumab-dttb | ONTRUZANT | VIAL | Pharmacy PA | N | ||
| trastuzumab-pkrb | HERZUMA | VIAL | Pharmacy PA | N | ||
| trastuzumab-strf | HERCESSI | VIAL | Pharmacy PA | N | ||
| tucatinib | TUKYSA | TABLET | Pharmacy PA | N | ||
| vemurafenib | ZELBORAF | TABLET | Pharmacy PA | N | ||
| venetoclax | VENCLEXTA STARTING PACK | TAB DS PK | Pharmacy PA | N | ||
| vismodegib | ERIVEDGE | CAPSULE | Pharmacy PA | N | ||
| vorasidenib citrate | VORANIGO | TABLET | Pharmacy PA | N | ||
| zanidatamab-hrii | ZIIHERA | VIAL | Pharmacy PA | N | ||
| zanubrutinib | BRUKINSA | TABLET | Pharmacy PA | N | ||
| zenocutuzumab-zbco | BIZENGRI | VIAL | Pharmacy PA | N | ||
| ziv-aflibercept | ZALTRAP | VIAL | Pharmacy PA | N | ||
| zongertinib | HERNEXEOS | TABLET | Pharmacy PA | N |