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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
mitoxantrone HCl MITOXANTRONE HCL VIAL N    
alemtuzumab CAMPATH VIAL    
alitretinoin PANRETIN GEL (GRAM)    
aminolevulinic acid HCl AMELUZ GEL (GRAM)   May 25, 2017
aminolevulinic acid HCl LEVULAN SOL W/APPL   May 25, 2017
anastrozole ANASTROZOLE TABLET    
anastrozole ARIMIDEX TABLET    
arsenic trioxide ARSENIC TRIOXIDE VIAL    
arsenic trioxide TRISENOX VIAL    
azacitidine VIDAZA VIAL    
azacitidine AZACITIDINE VIAL    
BCG live BCG (TICE STRAIN) VIAL    
bevacizumab-awwb MVASI VIAL    
bevacizumab-bvzr ZIRABEV VIAL    
bevacizumab-maly ALYMSYS VIAL    
bexarotene BEXAROTENE CAPSULE    
bexarotene TARGRETIN CAPSULE    
bexarotene BEXAROTENE GEL (GRAM)    
bexarotene TARGRETIN GEL (GRAM)    
bicalutamide CASODEX TABLET    
bicalutamide BICALUTAMIDE TABLET    
bleomycin sulfate BLEOMYCIN SULFATE VIAL    
bortezomib BORTEZOMIB VIAL    
bortezomib VELCADE VIAL    
busulfan MYLERAN TABLET    
busulfan BUSULFEX VIAL    
busulfan BUSULFAN VIAL    
capecitabine CAPECITABINE TABLET    
capecitabine XELODA TABLET    
carboplatin PARAPLATIN VIAL    
carboplatin CARBOPLATIN VIAL    
carmustine BICNU VIAL    
carmustine CARMUSTINE VIAL    
carmustine in polifeprosan 20 GLIADEL WAFER    
cetuximab ERBITUX VIAL    
chlorambucil LEUKERAN TABLET    
cisplatin CISPLATIN VIAL    
cladribine CLADRIBINE VIAL    
clofarabine CLOFARABINE VIAL    
clofarabine CLOLAR VIAL    
cyclophosphamide CYCLOPHOSPHAMIDE CAPSULE    
cyclophosphamide CYCLOPHOSPHAMIDE TABLET    
cyclophosphamide NEOSAR VIAL    
cyclophosphamide CYCLOPHOSPHAMIDE VIAL    
cytarabine CYTARABINE VIAL    
cytarabine/PF CYTARABINE VIAL    
dacarbazine DACARBAZINE VIAL    
dactinomycin DACTINOMYCIN VIAL    
dactinomycin COSMEGEN VIAL    
dasatinib SPRYCEL TABLET    
daunorubicin HCl DAUNORUBICIN HCL VIAL    
daunorubicin/cytarabine lipos VYXEOS VIAL    
decitabine DACOGEN VIAL    
decitabine DECITABINE VIAL    
docetaxel DOCETAXEL VIAL    
doxorubicin HCl DOXORUBICIN HCL VIAL    
doxorubicin HCl RUBEX VIAL    
doxorubicin HCl ADRIAMYCIN VIAL    
doxorubicin HCl ADRIAMYCIN RDF VIAL    
doxorubicin HCl peg-liposomal DOXIL VIAL    
doxorubicin HCl peg-liposomal DOXORUBICIN HCL LIPOSOME VIAL    
epirubicin HCl ELLENCE VIAL    
epirubicin HCl EPIRUBICIN HCL VIAL    
erlotinib HCl ERLOTINIB HCL TABLET    
erlotinib HCl TARCEVA TABLET    
estramustine phosphate sodium EMCYT CAPSULE    
etoposide ETOPOSIDE CAPSULE    
etoposide TOPOSAR VIAL    
etoposide ETOPOSIDE VIAL    
etoposide phosphate ETOPOPHOS VIAL    
exemestane EXEMESTANE TABLET    
exemestane AROMASIN TABLET    
floxuridine FLOXURIDINE VIAL    
fludarabine phosphate FLUDARABINE PHOSPHATE VIAL    
fluorouracil FLUOROURACIL CREAM (G)    
fluorouracil EFUDEX CREAM (G)    
fluorouracil CARAC CREAM (G)    
fluorouracil FLUOROURACIL SOLUTION    
fluorouracil FLUOROURACIL VIAL    
flutamide FLUTAMIDE CAPSULE    
fulvestrant FASLODEX SYRINGE    
fulvestrant FULVESTRANT SYRINGE    
gefitinib IRESSA TABLET    
gemcitabine HCl GEMCITABINE HCL VIAL    
gemcitabine HCl in 0.9 % NaCl INFUGEM PIGGYBACK    
gemtuzumab ozogamicin MYLOTARG VIAL    
idarubicin HCl IDARUBICIN HCL VIAL    
idarubicin HCl IDAMYCIN PFS VIAL    
ifosfamide IFOSFAMIDE VIAL    
ifosfamide IFEX VIAL    
imatinib mesylate GLEEVEC TABLET    
imatinib mesylate IMATINIB MESYLATE TABLET    
interferon alfa-2b,recomb. INTRON A VIAL    
interferon gamma-1b,recomb. ACTIMMUNE VIAL    
iobenguane iodine-131 AZEDRA THERAPEUTIC VIAL    
iobenguane iodine-131 AZEDRA DOSIMETRIC VIAL    
irinotecan HCl CAMPTOSAR VIAL    
irinotecan HCl IRINOTECAN HCL VIAL    
irinotecan liposomal ONIVYDE VIAL    
ixabepilone IXEMPRA VIAL    
kit Y-90/ibritumomab/h.albumin ZEVALIN KIT    
lapatinib ditosylate TYKERB TABLET    
lapatinib ditosylate LAPATINIB TABLET    
lenalidomide LENALIDOMIDE CAPSULE    
lenalidomide REVLIMID CAPSULE    
letrozole FEMARA TABLET    
letrozole LETROZOLE TABLET    
mechlorethamine HCl VALCHLOR GEL (GRAM)    
megestrol acetate MEGESTROL ACETATE TABLET    
melphalan ALKERAN TABLET    
melphalan MELPHALAN TABLET    
melphalan HCl ALKERAN VIAL    
melphalan HCl MELPHALAN HCL VIAL    
melphalan HCl/betadex sbes EVOMELA VIAL    
mercaptopurine PURIXAN ORAL SUSP    
mercaptopurine MERCAPTOPURINE TABLET    
methotrexate XATMEP SOLUTION    
methotrexate sodium METHOTREXATE TABLET    
methotrexate sodium TREXALL TABLET    
methotrexate sodium METHOTREXATE VIAL    
methotrexate sodium/PF METHOTREXATE VIAL    
methotrexate sodium/PF METHOTREXATE SODIUM VIAL    
mitomycin JELMYTO KIT    
mitomycin MITOMYCIN VIAL    
mitotane LYSODREN TABLET    
nelarabine ARRANON VIAL    
nelarabine NELARABINE VIAL    
nilotinib HCl TASIGNA CAPSULE    
nilutamide NILUTAMIDE TABLET    
oxaliplatin OXALIPLATIN VIAL    
paclitaxel PACLITAXEL VIAL    
paclitaxel protein-bound PACLITAXEL PROTEIN-BOUND VIAL    
paclitaxel protein-bound ABRAXANE VIAL    
panitumumab VECTIBIX VIAL    
pegaspargase ONCASPAR VIAL    
pemetrexed disodium PEMETREXED DISODIUM VIAL    
pemetrexed disodium ALIMTA VIAL    
pentostatin NIPENT VIAL    
plicamycin MITHRACIN VIAL    
procarbazine HCl MATULANE CAPSULE    
rituximab/hyaluronidase,human RITUXAN HYCELA VIAL    
sorafenib tosylate SORAFENIB TABLET    
sorafenib tosylate NEXAVAR TABLET    
streptozocin ZANOSAR VIAL    
sunitinib malate SUTENT CAPSULE    
sunitinib malate SUNITINIB MALATE CAPSULE    
tamoxifen citrate SOLTAMOX SOLUTION    
tamoxifen citrate TAMOXIFEN CITRATE TABLET    
temozolomide TEMODAR CAPSULE    
temozolomide TEMOZOLOMIDE CAPSULE    
temozolomide TEMODAR VIAL    
temsirolimus TORISEL VIAL    
temsirolimus TEMSIROLIMUS VIAL    
teniposide TENIPOSIDE AMPUL    
thioguanine TABLOID TABLET    
thiotepa THIOTEPA VIAL    
thiotepa TEPADINA VIAL    
topotecan HCl HYCAMTIN CAPSULE    
topotecan HCl HYCAMTIN VIAL    
topotecan HCl TOPOTECAN HCL VIAL    
toremifene citrate FARESTON TABLET    
toremifene citrate TOREMIFENE CITRATE TABLET    
trastuzumab HERCEPTIN VIAL    
tretinoin TRETINOIN CAPSULE    
valrubicin VALSTAR VIAL    
valrubicin VALRUBICIN VIAL    
vinblastine sulfate VINBLASTINE SULFATE VIAL    
vincristine sulfate VINCASAR PFS VIAL    
vincristine sulfate VINCRISTINE SULFATE VIAL    
vincristine sulfate liposomal MARQIBO KIT    
vinorelbine tartrate VINORELBINE TARTRATE VIAL    
vorinostat ZOLINZA CAPSULE