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