Antineoplastics, Older
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 |
|---|---|---|---|---|---|---|
| mitoxantrone HCl | MITOXANTRONE HCL | VIAL | N | |||
| alemtuzumab | CAMPATH | VIAL | ||||
| anastrozole | ARIMIDEX | TABLET | ||||
| anastrozole | ANASTROZOLE | TABLET | ||||
| arsenic trioxide | TRISENOX | VIAL | ||||
| arsenic trioxide | ARSENIC TRIOXIDE | VIAL | ||||
| azacitidine | VIDAZA | VIAL | ||||
| azacitidine | AZACITIDINE | VIAL | ||||
| BCG live | BCG (TICE STRAIN) | VIAL | ||||
| bevacizumab-adcd | VEGZELMA | VIAL | ||||
| bevacizumab-awwb | MVASI | VIAL | ||||
| bevacizumab-bvzr | ZIRABEV | VIAL | ||||
| bevacizumab-maly | ALYMSYS | VIAL | ||||
| bevacizumab-nwgd | JOBEVNE | VIAL | ||||
| bexarotene | BEXAROTENE | CAPSULE | ||||
| bexarotene | BEXAROTENE | GEL (GRAM) | ||||
| bicalutamide | CASODEX | TABLET | ||||
| bicalutamide | BICALUTAMIDE | TABLET | ||||
| bleomycin sulfate | BLEOMYCIN SULFATE | VIAL | ||||
| bortezomib | VELCADE | VIAL | ||||
| bortezomib | BORUZU | VIAL | ||||
| bortezomib | BORTEZOMIB | VIAL | ||||
| busulfan | BUSULFEX | VIAL | ||||
| busulfan | BUSULFAN | VIAL | ||||
| capecitabine | CAPECITABINE | TABLET | ||||
| capecitabine | XELODA | TABLET | ||||
| carboplatin | CARBOPLATIN | VIAL | ||||
| carboplatin | KYXATA | VIAL | ||||
| carmustine | CARMUSTINE | VIAL | ||||
| carmustine | BICNU | VIAL | ||||
| carmustine in polifeprosan 20 | GLIADEL | WAFER | ||||
| cetuximab | ERBITUX | VIAL | ||||
| cisplatin | KEMOPLAT | VIAL | ||||
| cisplatin | CISPLATIN | VIAL | ||||
| cladribine | CLADRIBINE | VIAL | ||||
| clofarabine | CLOFARABINE | VIAL | ||||
| cyclophosphamide | CYCLOPHOSPHAMIDE | CAPSULE | ||||
| cyclophosphamide | CYCLOPHOSPHAMIDE | TABLET | ||||
| cyclophosphamide | FRINDOVYX | VIAL | ||||
| cyclophosphamide | CYCLOPHOSPHAMIDE | VIAL | ||||
| cyclophosphamide | NEOSAR | VIAL | ||||
| cytarabine | CYTARABINE | VIAL | ||||
| cytarabine/PF | CYTARABINE | VIAL | ||||
| dacarbazine | DACARBAZINE | VIAL | ||||
| dactinomycin | DACTINOMYCIN | VIAL | ||||
| dasatinib | SPRYCEL | TABLET | ||||
| dasatinib | DASATINIB | TABLET | ||||
| daunorubicin HCl | DAUNORUBICIN HCL | VIAL | ||||
| daunorubicin/cytarabine lipos | VYXEOS | VIAL | ||||
| decitabine | DECITABINE | VIAL | ||||
| docetaxel | DOCIVYX | VIAL | ||||
| docetaxel | DOCETAXEL | VIAL | ||||
| docetaxel | BEIZRAY | VIAL | ||||
| doxorubicin HCl | ADRIAMYCIN RDF | VIAL | ||||
| doxorubicin HCl | ADRIAMYCIN | VIAL | ||||
| doxorubicin HCl | DOXORUBICIN HCL | VIAL | ||||
| doxorubicin HCl peg-liposomal | DOXORUBICIN HCL LIPOSOME | VIAL | ||||
| doxorubicin HCl peg-liposomal | DOXIL | VIAL | ||||
| doxorubicin HCl peg-liposomal | CAELYX | VIAL | ||||
| epirubicin HCl | EPIRUBICIN HCL | VIAL | ||||
| epirubicin HCl | ELLENCE | VIAL | ||||
| erlotinib HCl | ERLOTINIB HCL | TABLET | ||||
| etoposide | ETOPOSIDE | CAPSULE | ||||
| etoposide | ETOPOSIDE | VIAL | ||||
| etoposide phosphate | ETOPOPHOS | VIAL | ||||
| exemestane | EXEMESTANE | TABLET | ||||
| exemestane | AROMASIN | TABLET | ||||
| fludarabine phosphate | FLUDARABINE PHOSPHATE | VIAL | ||||
| fluorouracil | FLUOROURACIL | VIAL | ||||
| fulvestrant | FULVESTRANT | SYRINGE | ||||
| fulvestrant | FASLODEX | SYRINGE | ||||
| gefitinib | IRESSA | TABLET | ||||
| gefitinib | GEFITINIB | TABLET | ||||
| gemcitabine HCl | INLEXZO | IMPLANT | ||||
| gemcitabine HCl | GEMCITABINE HCL | VIAL | ||||
| gemcitabine HCl | AVGEMSI | VIAL | ||||
| gemtuzumab ozogamicin | MYLOTARG | VIAL | ||||
| idarubicin HCl | IDARUBICIN HCL | VIAL | ||||
| idarubicin HCl | IDAMYCIN PFS | VIAL | ||||
| ifosfamide | IFOSFAMIDE | VIAL | ||||
| ifosfamide | IFEX | VIAL | ||||
| imatinib mesylate | IMKELDI | SOLUTION | ||||
| imatinib mesylate | GLEEVEC | TABLET | ||||
| imatinib mesylate | IMATINIB MESYLATE | TABLET | ||||
| interferon gamma-1b,recomb. | ACTIMMUNE | VIAL | ||||
| irinotecan HCl | IRINOTECAN HCL | VIAL | ||||
| irinotecan HCl | CAMPTOSAR | 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 | REVLIMID | CAPSULE | ||||
| lenalidomide | LENALIDOMIDE | CAPSULE | ||||
| letrozole | LETROZOLE | TABLET | ||||
| letrozole | FEMARA | TABLET | ||||
| lomustine | LOMUSTINE | CAPSULE | ||||
| mechlorethamine HCl | VALCHLOR | GEL (GRAM) | ||||
| megestrol acetate | MEGESTROL ACETATE | TABLET | ||||
| melphalan HCl | MELPHALAN HCL | VIAL | ||||
| melphalan HCl | IVRA | VIAL | ||||
| melphalan HCl/betadex sbes | EVOMELA | VIAL | ||||
| mercaptopurine | PURIXAN | ORAL SUSP | ||||
| mercaptopurine | MERCAPTOPURINE | ORAL SUSP | ||||
| mercaptopurine | MERCAPTOPURINE | TABLET | ||||
| methotrexate | XATMEP | SOLUTION | ||||
| methotrexate | JYLAMVO | 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 | ZUSDURI | KIT | ||||
| mitomycin | MITOMYCIN | VIAL | ||||
| mitotane | LYSODREN | TABLET | ||||
| nelarabine | ARRANON | VIAL | ||||
| nelarabine | NELARABINE | VIAL | ||||
| nilotinib HCl | TASIGNA | CAPSULE | ||||
| nilotinib HCl | NILOTINIB HCL | 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 | PEMRYDI RTU | 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 | ||||
| sunitinib malate | SUNITINIB MALATE | CAPSULE | ||||
| sunitinib malate | SUTENT | CAPSULE | ||||
| tamoxifen citrate | SOLTAMOX | SOLUTION | ||||
| tamoxifen citrate | TAMOXIFEN CITRATE | TABLET | ||||
| temozolomide | TEMOZOLOMIDE | CAPSULE | ||||
| temozolomide | TEMODAR | VIAL | ||||
| temsirolimus | TEMSIROLIMUS | VIAL | ||||
| temsirolimus | TORISEL | VIAL | ||||
| thiotepa | TEPADINA | PLAST. BAG | ||||
| thiotepa | TEPADINA | VIAL | ||||
| thiotepa | TEPYLUTE | VIAL | ||||
| thiotepa | THIOTEPA | VIAL | ||||
| topotecan HCl | HYCAMTIN | CAPSULE | ||||
| topotecan HCl | TOPOTECAN HCL | VIAL | ||||
| toremifene citrate | TOREMIFENE CITRATE | TABLET | ||||
| toremifene citrate | FARESTON | TABLET | ||||
| trastuzumab | HERCEPTIN | VIAL | ||||
| tretinoin | TRETINOIN | CAPSULE | ||||
| valrubicin | VALRUBICIN | VIAL | ||||
| valrubicin | VALSTAR | VIAL | ||||
| vinblastine sulfate | VINBLASTINE SULFATE | VIAL | ||||
| vincristine sulfate | VINCASAR PFS | VIAL | ||||
| vincristine sulfate | VINCRISTINE SULFATE | VIAL | ||||
| vinorelbine tartrate | VINORELBINE TARTRATE | VIAL | ||||
| vorinostat | ZOLINZA | CAPSULE |