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ph-1069

Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary Pt. 1

Policy Number: PH-1069

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx, and Health Insurance Marketplace formularies.

POLICY REVIEW CYCLE

Effective Date	Date of Origin
7/1/2023

FDA APPROVED INDICATIONS AND DOSAGE

See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

For the purposes of the Self-Administered Oncology Agents criteria, indications deemed appropriate are those approved in FDA labeling and/or supported by NCCN Drugs & Biologics compendia with a category 1 or 2A recommendation, AHFS, or DrugDex with level of evidence of 1 or 2A.

Safety (3-111)

Agent(s)	Contraindication(s)
Afinitor/Afinitor Disperz (everolimus)	Hypersensitivity to everolimus, to other rapamycin derivatives
Alecensa (alectinib)	None
Alunbrig (brigatinib)	None
Ayvakit (avapritinib)	None
Balversa (erdafitinib)	None
BESREMi (ropeginterferon alfa-2b-njft)	Existence of, or history of severe psychiatric disorders, particularly severe depression, suicidal ideation, or suicide attempt; Hypersensitivity to interferons including interferon alfa-2b or any of the inactive ingredients of BESREMi; Moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment; History or presence of active serious or untreated autoimmune disease; Immunosuppressed transplant recipients
Bosulif (bosutinib)	Hypersensitivity to bosutinib
Braftovi (encorafenib)	None
Brukinsa (zanubrutinib)	None
Cabometyx (cabozantinib)	None
Calquence (acalabrutinib)	None
Caprelsa (vandetanib)	Congenital long QT syndrome
Cometriq (cabozantinib)	None
Copiktra (duvelisib)	None
Cotellic (cobimetinib)	None
Daurismo (glasdegib)	None
Erivedge (vismodegib)	None
Erleada (apalutamide)	None
Exkivity (mobocertinib)	None
Farydak (panobinostat)	None
Fotivda (tivozanib)	None
Gavreto (pralsetinib)	None
Gilotrif (afatinib)	None
Gleevec (imatinib)	None
Hycamtin (topotecan)	Severe hypersensitivity to topotecan
Ibrance (palbociclib)	None
Iclusig (ponatinib)	None
Idhifa (enasidenib)	None
Imbruvica (ibrutinib)	None
Inlyta (axitinib)	None
Inqovi (decitabine/ cedazuridine)	None
Inrebic (fedratinib)	None
Iressa (gefitinib)	None
Jakafi (ruxolitinib)	None
Jaypirca (pirobrutinib)	None
Kisqali (ribociclib)	None
Kisqali Femara Pack (ribociclib and letrozole co-packaged)	Hypersensitivity to letrozole, or any excipients of Femara
Koselugo (selumetinib)	None
Krazati (adagrasib)	None
Lenvima (lenvatinib)	None
Lonsurf (trifluridine/tipiracil)	None
Lorbrena (lorlatinib)	Concomitant use with a strong CYP3A inducer, due to potential for serious hepatotoxicity
Lumakras (sotorasib)	None
Lynparza (olaparib) tablets	None
Lysodren (mitotane)	None
Lytgobi (futibatinib)	None
Matulane (procarbazine)	Known hypersensitivity to procarbazine, inadequate marrow reserve
Mekinist (trametinib)	None
Mektovi (binimetinib)	None
Nerlynx (neratinib)	None
Nexavar (sorafenib)	Known severe hypersensitivity to sorafenib or its components, use in combination with carboplatin and paclitaxel in patients with squamous cell lung cancer
Ninlaro (ixazomib)	None
Nubeqa (darolutamide)	None
Odomzo (sonidegib)	None
Onureg (azacitidine)	Known severe hypersensitivity to azacitidine or its components
Orgovyx (relugolix)	None
Orserdu (elacestrant)	None
Pemazyre (pemigatinib)	None
Piqray (alpelisib)	Severe hypersensitivity to Piqray or to any of its components
Pomalyst (pomalidomide)	Pregnancy, severe hypersensitivity to pomalidomide or any of the excipients
Qinlock (ripretinib)	None
Retevmo (selpercatinib)	None
Revlimid (lenalidomide)	Pregnancy, severe hypersensitivity to lenalidomide
Rezlidhia (olutasidenib)	None
Rozlytrek (entrectinib)	None
Rubraca (rucaparib)	None
Rydapt (midostaurin)	Hypersensitivity to midostaurin or any of the excipients
Scemblix (asciminib)	None
Sprycel (dasatinib)	None
Stivarga (regorafenib)	None
Sutent (sunitinib)	None
Tabrecta (capmatinib)	None
Tafinlar (dabrafenib)	None
Tagrisso (osimertinib)	None
Talzenna (talazoparib)	None
Tarceva (erlotinib)	None
Targretin (bexarotene) capsules	Pregnancy; known serious hypersensitivity to bexarotene or other components of the product
Targretin (bexarotene) gel	known serious hypersensitivity to bexarotene or other components of the product
Tasigna (nilotinib)	Hypokalemia, hypomagnesemia, long QT syndrome
Tazverik (tazemetostat)	None
Temodar (temozolomide)	Hypersensitivity to dacarbazine (DTIC) or Temodar components
Tepmetko (tepotinib)	None
Thalomid (thalidomide)	Pregnancy, hypersensitivity to thalidomide or its components
Tibsovo (ivosidenib)	None
Tretinoin (oral)	known hypersensitivity to tretinoin, any of its components, or other retinoids; sensitivity to parabens
Truseltiq (infigratinib)	None
Tukysa (tucatinib)	None
Turalio (pexidartinib)	None
Tykerb (lapatinib)	Known hypersensitivity to lapatinib or its components
Venclexta (venetoclax)	Concomitant use with strong CYP3A inhibitors at initiation and during ramp-up phase in patients with CLL/SLL
Verzenio (abemaciclib)	None
Vitrakvi (larotrectinib)	None
Vizimpro (dacomitinib)	None
Vonjo (pacritinib)	Concomitant use of a strong CYP3A4 inhibitor or inducer
Votrient (pazopanib)	None
Welireg (belzutifan)	None
Xalkori (crizotinib)	None
Xeloda (capecitabine)	Severe renal failure, hypersensitivity to capecitabine or any of its components, hypersensitivity to 5-fluorouracil
Xospata (gilteritinib)	Hypersensitivity to gilteritinib or any of the excipients
Xpovio (selinexor)	None
Xtandi (enzalutamide)	None
Yonsa (abiraterone acetate)	None
Zejula (niraparib)	None
Zelboraf (vemurafenib)	None
Zolinza (vorinostat)	None
Zydelig (idelalisib)	History of serious allergic reactions including anaphylaxis and toxic epidermal necrolysis
Zykadia (ceritinib)	None
Zytiga (abiraterone)	None

REFERENCES

Number	Reference
1	Sacco Jj, Botten J, Macbeth F, et al. The average body surface area of adult cancer patients in the UK: A multicentre retrospective study. PLoS ONE 5(1):e8933. Doi:10.1371/journal.pone.0008933.
2	Verbraecken J et al. Body surface area in normal-weight, overweight, and obese adults. A Comparison study. Metabolism Clinical and Experimental 2006;55:515-524.
3	Afinitor/Afinitor Disperz prescribing information. Novartis. February 2022.
4	Alecensa prescribing information. Hoffmann-La Roche. September 2021.
5	Alunbrig prescribing information. Takeda Pharms USA. February 2022.
6	Ayvakit prescribing information. Blueprint Medicines Corp. June 2021.
7	Balversa prescribing information. Janssen Pharmaceutical Companies. April 2022.
8	BESREMi prescribing information. Pharmaessentia Corp. November 2021.
9	Bosulif prescribing information. Pfizer Inc. May 2021.
10	Braftovi prescribing information. Array BioPharma Inc. February 2022.
11	Brukinsa prescribing information. BeiGene, Ltd. September 2021.
12	Cabometyx prescribing information. Exelixis Inc. July 2022.
13	Calquence prescribing information. AstraZeneca. March 2022.
14	Caprelsa prescribing information. AstraZeneca Pharmaceuticals. March 2022.
15	Cometriq prescribing information. Exelixis, Inc. October 2020.
16	Copiktra prescribing information. Verastem, Inc. February 2022.
17	Cotellic prescribing information. Genentech. January 2018.
18	Daurismo prescribing information. Pfizer Inc. March 2020.
19	Erivedge prescribing information. Genentech. July 2020.
20	Erleada prescribing information. Janssen Ortho LLC. April 2022.
21	Exkivity prescribing information. Takeda Pharms USA. September 2021.
22	Farydak prescribing information. Novartis. December 2017.
23	Fotivda prescribing information. Aveo Pharmaceuticals, Inc. March 2021.
24	Gavreto prescribing information. Genentech Inc. February 2022.
25	Gilotrif prescribing information. Boehringer Ingelheim Pharmaceuticals. April 2022.
26	Gleevec prescribing information. Novartis. March 2022.
27	Hycamtin prescribing Information. Novartis. September 2018.
28	Ibrance prescribing information. Pfizer. November 2019.
29	Iclusig prescribing Information. Takeda Pharms USA. February 2022.
30	Idhifa prescribing information. Celgene. November 2020.
31	Imbruvica prescribing information. Pharmacyclics, Inc. August 2022.
32	Inlyta prescribing information. Pfizer. New York, NY. June 2020.
33	Inqovi prescribing information. Otsuka Pharmaceutical Co., LTD. March 2022.
34	Inrebic prescribing information. Impact Biomedicines, Inc. December 2021.
35	Iressa prescribing information. AstraZeneca. May 2021.
36	Jakafi prescribing information. Incyte. September 2021.
37	Kisqali Femara Pack prescribing information. Novartis. December 2021.
38	Kisqali prescribing information. Novartis. December 2021.
39	Koselugo prescribing information. AstraZeneca. December 2021.
40	Lenvima prescribing information. Eisai. December 2021.
41	Lonsurf prescribing information. Taiho Oncology. January 2020.
42	Lorbrena prescribing information. Pfizer Inc. March 2021.
43	Lumakras prescribing information. Amgen Inc. May 2021.
44	Lynparza tablets prescribing information. AstraZeneca. March 2022.
45	Lysodren prescribing Information. E.R. Squibb & Sons, L.L.C. June 2021.
46	Matulane prescribing Information. Sigma-tau. August 2018.
47	Mekinist prescribing information. Novartis. June 2022.
48	Mektovi prescribing information. Array BioPharma Inc. January 2019.
49	Nerlynx prescribing information. Puma Biotech. June 2021.
50	Nexavar prescribing information. Bayer. May 2021.
51	Ninlaro prescribing information. Millennium. April 2022.
52	Nubeqa prescribing information. Bayer HealthCare Pharmaceuticals Inc. January 2021.
53	Odomzo prescribing information. Sun Pharm. May 2019.
54	Onureg prescribing information. Celgene Corporation. May 2021.
55	Orgovyx prescribing information. Myovant Sciences, Inc. December 2020.
56	Pemazyre prescribing information. Incyte Corp. February 2021.
57	Piqray prescribing information. Novartis Pharmaceuticals Corp. May 2022.
58	Pomalyst prescribing information. Celgene Corporation. October 2021.
59	Qinlock prescribing information. Deciphera Pharmaceuticals, LLC. June 2021.
60	Retevmo prescribing information. Lilly USA, LLC. January 2021.
61	Revlimid prescribing information. Celgene Corporation. May 2022.
62	Rozlytrek prescribing information. Genentech USA, Inc. November 2021.
63	Rubraca prescribing information. Clovis Oncology. June 2022.
64	Rydapt prescribing information. Novartis. November 2021.
65	Scemblix prescribing information. Novartis Pharms Corp. October 2021.
66	Sprycel prescribing information. E.R. Squibb & Sons, L.L.C. June 2021.
67	Stivarga prescribing information. Bayer Healthcare Pharmaceuticals. December 2020.
68	Sutent prescribing information. CPPI CV. August 2021.
69	Tabrecta prescribing information. Novartis Pharmaceuticals Corp. January 2022.
70	Tafinlar prescribing information. Novartis. June 2022.
71	Tagrisso prescribing information. AstraZeneca. January 2022.
72	Talzenna prescribing information. Pfizer Inc. September 2021.
73	Tarceva prescribing information. Genentech. October 2016.
74	Targretin capsule prescribing information. Valeant. April 2020.
75	Targretin gel prescribing information. Bausch Health US, LLC. February 2020.
76	Tasigna prescribing information. Novartis. September 2021.
77	Tazverik prescribing information. Epizyme Inc. January 2020.
78	Temodar prescribing Information. Merck Sharp & Dohme Corp. November 2020.
79	Tepmetko prescribing information. EMD Serono, Inc. February 2021.
80	Thalomid prescribing information. Celgene Corporation. February 2021.
81	Tibsovo prescribing information. Agios Pharmaceuticals, Inc. May 2022.
82	Tretinoin prescribing information. Glenmark Pharmaceuticals, Inc. January 2018.
83	Truseltiq prescribing information. QED Therapeutics Inc. May 2021.
84	Tukysa prescribing information. Seattle Genetics. April 2020.
85	Turalio prescribing information. Daiichi Sankyo, Inc. December 2022.
86	Tykerb prescribing information. GSK. March 2022.
87	~~Ukoniq prescribing information. TG Therapeutics. February 2021.~~ Reference is no longer used
88	Venclexta prescribing information. AbbVie Inc. June 2022.
89	Verzenio prescribing information. Eli Lilly and Company. October 2021.
90	Vitrakvi prescribing information. Loxo Oncology, Inc. March 2021.
91	Vizimpro prescribing information. Pfizer Inc. December 2020.
92	Votrient prescribing information. GSK. December 2021.
93	Welireg prescribing information. Merck Sharp & Dohme Corp. August 2021.
94	Xalkori prescribing information. Pfizer. July 2022.
95	Xeloda prescribing information. Hoffmann La Roche. May 2021.
96	Xospata prescribing information. Astellas Pharma Inc. January 2022.
97	Xpovio prescribing information. Karyopharm Therapeutics Inc. March 2022.
98	Xtandi prescribing information. Astellas Pharma US, Inc. January 2022.
99	Yonsa prescribing information. Sun Pharmaceuticals Inc. March 2022.
100	Zejula prescribing information. GSK. July 2021.
101	Zelboraf prescribing information. Genentech, USA. May 2020.
102	Zolinza prescribing information. Merck Sharp & Dohme Corp. December 2018.
103	Zydelig prescribing information. Gilead Sciences, Inc. October 2020.
104	Zykadia prescribing information. Novartis Pharmaceuticals. October 2021.
105	Zytiga prescribing information. Janssen Biotech, Inc. August 2021.
106	Vonjo prescribing information. CTI Biopharma Corp. February 2022.
107	Lytgobi prescribing information. Taiho Pharmaceutical Co., LTD. September 2022.
108	Rezlidhia prescribing information. Forma Therapeutics, Inc. December 2022.
109	Krazati prescribing information. Mirati Therapeutics, Inc. December 2022.
110	Jaypirca prescribing information. Eli Lilly and Company. January 2023.
111	Orserdu prescribing information. Stemline Therapeutics, Inc. January 2023.

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Target Brand Agent(s)	Target Generic Agent(s)	Strength	Targeted MSC	Available MSC	Preferred Status	Effective Date

Verzenio	abemaciclib tab	100 MG ; 150 MG ; 200 MG ; 50 MG	M ; N ; O ; Y	N
Yonsa	abiraterone acetate tab	125 MG	M ; N ; O ; Y	N
Zytiga	abiraterone acetate tab	250 MG ; 500 MG	M ; N ; O ; Y	O ; Y
Calquence	acalabrutinib cap	100 MG	M ; N ; O ; Y	N
Calquence	acalabrutinib cap	100 MG	M ; N ; O ; Y	N
Calquence	acalabrutinib maleate tab	100 MG	M ; N ; O ; Y	N		01-01-2023
Krazati	adagrasib tab	200 MG	M ; N ; O ; Y	N		04-01-2023
Gilotrif	afatinib dimaleate tab	20 MG ; 30 MG ; 40 MG	M ; N ; O ; Y	N
Gilotrif	afatinib dimaleate tab	20 MG ; 30 MG ; 40 MG	M ; N ; O ; Y	N
Alecensa	alectinib hcl cap	150 MG	M ; N ; O ; Y	N
Alecensa	alectinib hcl cap	150 MG	M ; N ; O ; Y	N
Piqray 200mg daily dose ; Piqray 250mg daily dose ; Piqray 300mg daily dose	alpelisib tab pack ; alpelisib tab therapy pack	150 MG ; 200 MG	M ; N ; O ; Y	N
Erleada	apalutamide tab	240 MG ; 60 MG	M ; N ; O ; Y	N
Ayvakit	avapritinib tab	100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG	M ; N ; O ; Y	N
Ayvakit	avapritinib tab	100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG	M ; N ; O ; Y	N
Inlyta	axitinib tab	1 MG ; 5 MG	M ; N ; O ; Y	N
Inlyta	axitinib tab	1 MG ; 5 MG	M ; N ; O ; Y	N
Onureg	azacitidine tab	200 MG ; 300 MG	M ; N ; O ; Y	N
Welireg	belzutifan tab	40 MG	M ; N ; O ; Y	N
Targretin	bexarotene cap	75 MG	M ; N ; O ; Y	O ; Y
Targretin	Bexarotene Gel 1%	1 %	M ; N ; O ; Y	O ; Y
Mektovi	binimetinib tab	15 MG	M ; N ; O ; Y	N
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	M ; N ; O ; Y	N
Alunbrig	brigatinib tab	180 MG ; 30 MG ; 90 MG	M ; N ; O ; Y	N
Alunbrig	brigatinib tab ; brigatinib tab initiation therapy pack	180 MG ; 30 MG ; 90 MG	M ; N ; O ; Y	N
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 MG	M ; N ; O ; Y	N
Cometriq	cabozantinib s-mal cap ; cabozantinib s-malate cap	20 MG ; 3 80 MG ; 80 MG	M ; N ; O ; Y	N
Cabometyx	cabozantinib s-malate tab	20 MG ; 40 MG ; 60 MG	M ; N ; O ; Y	N
Xeloda	capecitabine tab	150 MG ; 500 MG	M ; N ; O ; Y	O ; Y
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	M ; N ; O ; Y	N
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	M ; N ; O ; Y	N
Zykadia	ceritinib tab	150 MG	M ; N ; O ; Y	N
Zykadia	ceritinib tab	150 MG	M ; N ; O ; Y	N
Cotellic	cobimetinib fumarate tab	20 MG	M ; N ; O ; Y	N
Xalkori	crizotinib cap	200 MG ; 250 MG	M ; N ; O ; Y	N
Xalkori	crizotinib cap	200 MG ; 250 MG	M ; N ; O ; Y	N
Tafinlar	dabrafenib mesylate cap	50 MG ; 75 MG	M ; N ; O ; Y	N
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	M ; N ; O ; Y	N
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	M ; N ; O ; Y	N
Nubeqa	darolutamide tab	300 MG	M ; N ; O ; Y	N
Sprycel	dasatinib tab	100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG	M ; N ; O ; Y	N
Inqovi	Decitabine-Cedazuridine Tab ; decitabine-cedazuridine tab	0 ; 35 MG	M ; N ; O ; Y	N
Inqovi	Decitabine-Cedazuridine Tab ; decitabine-cedazuridine tab	0 ; 35 MG	M ; N ; O ; Y	N
Copiktra	duvelisib cap	15 MG ; 25 MG	M ; N ; O ; Y	N
Orserdu	elacestrant hydrochloride tab	345 MG ; 86 MG	M ; N ; O ; Y	N		04-01-2023
Idhifa	enasidenib mesylate tab	100 MG ; 50 MG	M ; N ; O ; Y	N
Braftovi	encorafenib cap	75 MG	M ; N ; O ; Y	N
Rozlytrek	entrectinib cap	100 MG ; 200 MG	M ; N ; O ; Y	N
Xtandi	enzalutamide cap	40 MG	M ; N ; O ; Y	N
Xtandi	enzalutamide tab	40 MG ; 80 MG	M ; N ; O ; Y	N
Balversa	erdafitinib tab	3 MG ; 4 MG ; 5 MG	M ; N ; O ; Y	N
Tarceva	erlotinib hcl tab	100 MG ; 150 MG ; 25 MG	M ; N ; O ; Y	N ; O ; Y
Tarceva	erlotinib hcl tab	100 MG ; 150 MG ; 25 MG	M ; N ; O ; Y	N ; O ; Y
Afinitor	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	M ; N ; O ; Y	O ; Y
Afinitor	Everolimus Tab 10 MG	10 MG	M ; N ; O ; Y	O ; Y
Afinitor	Everolimus Tab 5 MG	5 MG	M ; N ; O ; Y	O ; Y
Afinitor disperz	everolimus tab for oral susp	2 MG ; 3 MG ; 5 MG	M ; N ; O ; Y	O ; Y
Inrebic	fedratinib hcl cap	100 MG	M ; N ; O ; Y	N
Lytgobi	futibatinib tab therapy pack	4 MG	M ; N ; O ; Y	N
Iressa	gefitinib tab	250 MG	M ; N ; O ; Y	N
Iressa	gefitinib tab	250 MG	M ; N ; O ; Y	N
Xospata	gilteritinib fumarate tablet	40 MG	M ; N ; O ; Y	N
Xospata	gilteritinib fumarate tablet	40 MG	M ; N ; O ; Y	N
Daurismo	glasdegib maleate tab	100 MG ; 25 MG	M ; N ; O ; Y	N
Imbruvica	ibrutinib cap ; ibrutinib oral susp ; ibrutinib tab	140 MG ; 280 MG ; 420 MG ; 560 MG ; 70 MG ; 70 MG/ML	M ; N ; O ; Y	N		01-01-2023
Zydelig	idelalisib tab	100 MG ; 150 MG	M ; N ; O ; Y	N
Gleevec	imatinib mesylate tab	100 MG ; 400 MG	M ; N ; O ; Y	O ; Y
Truseltiq	infigratinib phos cap pack ; infigratinib phos cap ther pack	100 MG ; 25 MG	M ; N ; O ; Y	N
Tibsovo	ivosidenib tab	250 MG	M ; N ; O ; Y	N
Ninlaro	ixazomib citrate cap	2.3 MG ; 3 MG ; 4 MG	M ; N ; O ; Y	N
Tykerb	lapatinib ditosylate tab	250 MG	M ; N ; O ; Y	N ; O ; Y
Tykerb	lapatinib ditosylate tab	250 MG	M ; N ; O ; Y	N ; O ; Y
Vitrakvi	larotrectinib sulfate cap	100 MG ; 25 MG	M ; N ; O ; Y	N
Vitrakvi	larotrectinib sulfate oral soln	20 MG/ML	M ; N ; O ; Y	N
Revlimid	lenalidomide cap ; lenalidomide caps	10 MG ; 15 MG ; 2.5 ; 2.5 MG ; 20 ; 20 MG ; 25 MG ; 5 MG	M ; N ; O ; Y	O ; Y
Lenvima 10 mg daily dose ; Lenvima 12mg daily dose ; Lenvima 14 mg daily dose ; Lenvima 18 mg daily dose ; Lenvima 20 mg daily dose ; Lenvima 24 mg daily dose ; Lenvima 4 mg daily dose ; Lenvima 8 mg daily dose	lenvatinib cap ther pack ; lenvatinib cap therapy pack	10 2 x 4 MG ; 10 MG ; 2 4 MG ; 4 MG	M ; N ; O ; Y	N
Lorbrena	lorlatinib tab	100 MG ; 25 MG	M ; N ; O ; Y	N
Lorbrena	lorlatinib tab	100 MG ; 25 MG	M ; N ; O ; Y	N
Rydapt	midostaurin cap	25 MG	M ; N ; O ; Y	N
Lysodren	mitotane tab	500 MG	M ; N ; O ; Y	N
Exkivity	mobocertinib succinate cap	40 MG	M ; N ; O ; Y	N
Nerlynx	neratinib maleate tab	40 MG	M ; N ; O ; Y	N
Nerlynx	neratinib maleate tab	40 MG	M ; N ; O ; Y	N
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	M ; N ; O ; Y	N
Zejula	niraparib tosylate cap	100 MG	M ; N ; O ; Y	N
Lynparza	olaparib tab	100 MG ; 150 MG	M ; N ; O ; Y	N
Rezlidhia	olutasidenib cap	150 MG	M ; N ; O ; Y	N		04-01-2023
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	M ; N ; O ; Y	N
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	M ; N ; O ; Y	N
Vonjo	pacritinib citrate cap	100 MG	M ; N ; O ; Y	N
Ibrance	palbociclib cap	100 MG ; 125 MG ; 75 MG	M ; N ; O ; Y	N
Ibrance	palbociclib cap ; palbociclib tab	100 MG ; 125 MG ; 75 MG	M ; N ; O ; Y	N
Farydak	panobinostat lactate cap	10 MG ; 15 MG ; 20 MG	M ; N ; O ; Y	N
Votrient	pazopanib hcl tab	200 MG	M ; N ; O ; Y	N
Votrient	pazopanib hcl tab	200 MG	M ; N ; O ; Y	N
Pemazyre	pemigatinib tab	13.5 MG ; 4.5 MG ; 9 MG	M ; N ; O ; Y	N
Turalio	pexidartinib hcl cap	125 MG ; 200 MG	M ; N ; O ; Y	N
Turalio	pexidartinib hcl cap	125 MG ; 200 MG	M ; N ; O ; Y	N
Jaypirca	pirtobrutinib tab	100 MG ; 50 MG	M ; N ; O ; Y	N		04-01-2023
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	M ; N ; O ; Y	N
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	M ; N ; O ; Y	N
Iclusig	ponatinib hcl tab	10 MG ; 15 MG ; 30 MG ; 45 MG	M ; N ; O ; Y	M ; N
Gavreto	pralsetinib cap	100 MG	M ; N ; O ; Y	N
Gavreto	pralsetinib cap	100 MG	M ; N ; O ; Y	N
Matulane	procarbazine hcl cap	50 MG	M ; N ; O ; Y	N
Stivarga	regorafenib tab	40 MG	M ; N ; O ; Y	N
Orgovyx	relugolix tab	120 MG	M ; N ; O ; Y	N
Kisqali femara 200 dose ; Kisqali femara 400 dose ; Kisqali femara 600 dose	ribociclib	200 MG	M ; N ; O ; Y	N
Kisqali	ribociclib succinate tab pack	200 MG	M ; N ; O ; Y	N
Qinlock	ripretinib tab	50 MG	M ; N ; O ; Y	N
Qinlock	ripretinib tab	50 MG	M ; N ; O ; Y	N
Rubraca	rucaparib camsylate tab	200 MG ; 250 MG ; 300 MG	M ; N ; O ; Y	N
Jakafi	ruxolitinib phosphate tab	10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG	M ; N ; O ; Y	N
Xpovio ; Xpovio 100 mg once weekly ; Xpovio 40 mg once weekly ; Xpovio 40 mg twice weekly ; Xpovio 60 mg once weekly ; Xpovio 60 mg twice weekly ; Xpovio 80 mg once weekly ; Xpovio 80 mg twice weekly	selinexor tab therapy pack	20 MG ; 40 MG ; 50 MG ; 60 MG	M ; N ; O ; Y	N
Retevmo	selpercatinib cap	40 MG ; 80 MG	M ; N ; O ; Y	N
Retevmo	selpercatinib cap	40 MG ; 80 MG	M ; N ; O ; Y	N
Koselugo	selumetinib sulfate cap	10 MG ; 25 MG	M ; N ; O ; Y	N
Odomzo	sonidegib phosphate cap	200 MG	M ; N ; O ; Y	N
Nexavar	sorafenib tosylate tab	200 MG	M ; N ; O ; Y	O ; Y
Lumakras	sotorasib tab	120 MG ; 320	M ; N ; O ; Y	N
Sutent	sunitinib malate cap	12.5 MG ; 25 MG ; 37.5 MG ; 50 MG	M ; N ; O ; Y	O ; Y
Talzenna	talazoparib tosylate cap	0.25 MG ; 0.5 MG ; 0.75 MG ; 1 MG	M ; N ; O ; Y	N
Tazverik	tazemetostat hbr tab	200 MG	M ; N ; O ; Y	N
Temodar	temozolomide cap	100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG	M ; N ; O ; Y	O ; Y
Thalomid	thalidomide cap	100 MG ; 150 MG ; 200 MG ; 50 MG	M ; N ; O ; Y	N
Fotivda	tivozanib hcl cap	0.89 MG ; 1.34 MG	M ; N ; O ; Y	N
Hycamtin	topotecan hcl cap	0.25 MG ; 1 MG	M ; N ; O ; Y	N
Mekinist	trametinib dimethyl sulfoxide tab	0.5 MG ; 2 MG	M ; N ; O ; Y	N
	tretinoin cap	10 MG	M ; N ; O ; Y	Y
Lonsurf	trifluridine-tipiracil tab	15 MG ; 20 MG	M ; N ; O ; Y	N
Tukysa	tucatinib tab	150 MG ; 50 MG	M ; N ; O ; Y	N
Tukysa	tucatinib tab	150 MG ; 50 MG	M ; N ; O ; Y	N
Caprelsa	vandetanib tab	100 MG ; 300 MG	M ; N ; O ; Y	N
Caprelsa	vandetanib tab	100 MG ; 300 MG	M ; N ; O ; Y	N
Zelboraf	vemurafenib tab	240 MG	M ; N ; O ; Y	N
Venclexta	venetoclax tab	10 MG ; 100 MG ; 50 MG	M ; N ; O ; Y	N
Venclexta starting pack	venetoclax tab therapy starter pack	10 MG	M ; N ; O ; Y	N
Erivedge	vismodegib cap	150 MG	M ; N ; O ; Y	N
Zolinza	vorinostat cap	100 MG	M ; N ; O ; Y	N
Brukinsa	zanubrutinib cap	80 MG	M ; N ; O ; Y	N
Brukinsa	zanubrutinib cap	80 MG	M ; N ; O ; Y	N
Scemblix	asciminib hcl tab	20 MG ; 40 MG	M ; N ; O ; Y	N	See Preferred Agents Detail
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	M ; N ; O ; Y	N	See Preferred Agents Detail
Sprycel	dasatinib tab	100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG	M ; N ; O ; Y	N	See Preferred Agents Detail
Gleevec	imatinib mesylate tab	100 MG ; 400 MG	M ; N ; O ; Y	O ; Y	See Preferred Agents Detail
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	M ; N ; O ; Y	N	See Preferred Agents Detail
Iclusig	ponatinib hcl tab	10 MG ; 15 MG ; 30 MG ; 45 MG	M ; N ; O ; Y	M ; N	See Preferred Agents Detail
Besremi	ropeginterferon alfa-	500 MCG/ML	M ; N ; O ; Y	N	See Preferred Agents Detail

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)	Target Generic Agent Name(s)	Strength	QL Amount	Dose Form	Day Supply	Duration	Addtl QL Info	Allowed Exceptions	Targeted NDCs When Exclusions Exist	Effective Date

Afinitor	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	30	TABS	30	DAYS
Afinitor disperz	Everolimus Tab for Oral Susp 2 MG	2 MG	60	TABS	30	DAYS	Calculation is based on 4.5 mg/m2 with a standard BSA of 2.0 and rounding up to nearest full dose
Afinitor disperz	Everolimus Tab for Oral Susp 3 MG	3 MG	90	TABS	30	DAYS
Afinitor disperz	Everolimus Tab for Oral Susp 5 MG	5 MG	60	TABS	30	DAYS
Alecensa	alectinib hcl cap	150 MG	240	CAPS	30	DAYS
Alunbrig	Brigatinib Tab	180 MG	30	TABS	30	DAYS
Alunbrig	Brigatinib Tab	90 MG	30	TABS	30	DAYS
Alunbrig	Brigatinib Tab	30 MG	120	TABS	30	DAYS
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 MG	30	TABS	180	DAYS
Ayvakit	avapritinib tab	100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG	30	TABS	30	DAYS
Balversa	Erdafitinib Tab 3 MG	3 MG	90	TABS	30	DAYS
Balversa	Erdafitinib Tab 4 MG	4 MG	60	TABS	30	DAYS
Balversa	Erdafitinib Tab 5 MG	5 MG	30	TABS	30	DAYS
Besremi	Ropeginterferon alfa-	500 MCG/ML	2	SYRNGS	28	DAYS
Bosulif	Bosutinib Tab	100 MG	90	TABS	30	DAYS
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	30	TABS	30	DAYS
Braftovi	encorafenib cap	75 MG	180	CAPS	30	DAYS
Brukinsa	Zanubrutinib Cap	80 MG	120	CAPS	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	20 MG	30	TABS	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	40 MG	30	TABS	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	60 MG	30	TABS	30	DAYS
Calquence	acalabrutinib cap	100 MG	60	CAPS	30	DAYS
Calquence	acalabrutinib maleate tab	100 MG	60	TABS	30	DAYS				01-01-2023
Caprelsa	Vandetanib Tab	300 MG	30	TABS	30	DAYS
Caprelsa	Vandetanib Tab	100 MG	60	TABS	30	DAYS
Cometriq	Cabozantinib S-Mal Cap	3 80 MG	1	CARTON	28	DAYS
Cometriq	Cabozantinib S-Mal Cap	80 MG	1	CARTON	28	DAYS
Cometriq	Cabozantinib S-Malate Cap	20 MG	1	CARTON	28	DAYS
Copiktra	duvelisib cap	15 MG ; 25 MG	56	CAPS	28	DAYS
Cotellic	cobimetinib fumarate tab	20 MG	63	TABS	28	DAYS
Daurismo	Glasdegib Maleate Tab 100 MG (Base Equivalent)	100 MG	30	TABS	30	DAYS
Daurismo	Glasdegib Maleate Tab 25 MG (Base Equivalent)	25 MG	60	TABS	30	DAYS
Erivedge	Vismodegib Cap 150 MG	150 MG	30	CAPS	30	DAYS
Erleada	apalutamide tab	240 MG	30	TABS	30	DAYS
Erleada	Apalutamide Tab 60 MG	60 MG	120	TABS	30	DAYS
Exkivity	Mobocertinib Succinate Cap	40 MG	120	CAPS	30	DAYS
Farydak	panobinostat lactate cap	10 MG ; 15 MG ; 20 MG	6	CAPS	21	DAYS
Fotivda	Tivozanib HCl Cap	0.89 MG	21	CAPS	28	DAYS
Fotivda	Tivozanib HCl Cap	1.34 MG	21	CAPS	28	DAYS
Gavreto	pralsetinib cap	100 MG	120	CAPS	30	DAYS
Gilotrif	afatinib dimaleate tab	20 MG ; 30 MG ; 40 MG	30	TABS	30	DAYS
Gleevec	Imatinib Mesylate Tab	100 MG	90	TABS	30	DAYS
Gleevec	Imatinib Mesylate Tab	400 MG	60		30	DAYS
Ibrance	palbociclib cap ; palbociclib tab	100 MG ; 125 MG ; 75 MG	21	CAPS	28	DAYS
Iclusig	Ponatinib HCl Tab	10 MG	30	TABS	30	DAYS
Iclusig	Ponatinib HCl Tab	15 MG	60	TABS	30	DAYS
Iclusig	Ponatinib HCl Tab	45 MG	30	TABS	30	DAYS
Iclusig	Ponatinib HCl Tab	30 MG	30	TABS	30	DAYS
Idhifa	Enasidenib Mesylate Tab 100 MG (Base Equivalent)	100 MG	30	TABS	30	DAYS
Idhifa	Enasidenib Mesylate Tab 50 MG (Base Equivalent)	50 MG	30	TABS	30	DAYS
Imbruvica	Ibrutinib Cap	70 MG	30	CAPS	30	DAYS
Imbruvica	Ibrutinib Cap	140 MG	90	CAPS	30	DAYS
Imbruvica	Ibrutinib Oral Susp	70 MG/ML	2	BOTTS	30	DAYS				01-01-2023
Imbruvica	ibrutinib tab	140 MG ; 280 MG ; 420 MG ; 560 MG	30	TABS	30	DAYS
Inlyta	Axitinib Tab	1 MG	180	TABS	30	DAYS
Inlyta	Axitinib Tab	5 MG	120	TABS	30	DAYS
Inqovi	Decitabine-Cedazuridine Tab ; decitabine-cedazuridine tab	0 ; 35 MG	5	TABS	28	DAYS
Inrebic	Fedratinib HCl Cap 100 MG	100 MG	120	CAPS	30	DAYS
Iressa	gefitinib tab	250 MG	30	TABS	30	DAYS
Jakafi	ruxolitinib phosphate tab	10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG	60	TABS	30	DAYS
Jaypirca	pirtobrutinib tab	100 MG	60	TABS	30	DAYS				04-01-2023
Jaypirca	pirtobrutinib tab	50 MG	30	TABS	30	DAYS				04-01-2023
Kisqali	Ribociclib Succinate Tab Pack 200 MG Daily Dose	200 MG	21	TABS	28	DAYS
Kisqali	Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab)	200 MG	42	TABS	28	DAYS
Kisqali	Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab)	200 MG	63	TABS	28	DAYS
Kisqali femara 200 dose	Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	49	TABS	28	DAYS
Kisqali femara 400 dose	Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	70	TABS	28	DAYS
Kisqali femara 600 dose	Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	91	TABS	28	DAYS
Koselugo	Selumetinib Sulfate Cap 10 MG	10 MG	240	CAPS	30	DAYS
Koselugo	Selumetinib Sulfate Cap 25 MG	25 MG	120	CAPS	30	DAYS
Krazati	Adagrasib Tab	200 MG	180	TABS	30	DAYS				04-01-2023
Lenvima 10 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	30	CAPS	30	DAYS
Lenvima 12mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	90	CAPS	30	DAYS
Lenvima 14 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	60	CAPS	30	DAYS
Lenvima 18 mg daily dose	Lenvatinib Cap Ther Pack	10 2 x 4 MG	90	CAPS	30	DAYS
Lenvima 20 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	60	CAPS	30	DAYS
Lenvima 24 mg daily dose	Lenvatinib Cap Ther Pack	2 4 MG	90	CAPS	30	DAYS
Lenvima 4 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	30	CAPS	30	DAYS
Lenvima 8 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	60	CAPS	30	DAYS
Lonsurf	Trifluridine-Tipiracil Tab 15-6.14 MG	15 MG	60	TABS	28	DAYS
Lonsurf	Trifluridine-Tipiracil Tab 20-8.19 MG	20 MG	80	TABS	28	DAYS
Lorbrena	Lorlatinib Tab	100 MG	30	TABS	30	DAYS
Lorbrena	Lorlatinib Tab	25 MG	90	TABS	30	DAYS
Lumakras	sotorasib tab	320	90	TABS	30	DAYS
Lumakras	Sotorasib Tab	120 MG	240	TABS	30	DAYS
Lynparza	olaparib tab	100 MG ; 150 MG	120	TABS	30	DAYS
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	140	TABS	28	DAYS				01-01-2023
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	112	TABS	28	DAYS				01-01-2023
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	84	TABS	28	DAYS				01-01-2023
Mekinist	Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)	0.5 MG	90	TABS	30	DAYS
Mekinist	Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)	2 MG	60	TABS	30	DAYS
Mektovi	binimetinib tab	15 MG	180	TABS	30	DAYS
Nerlynx	Neratinib Maleate Tab	40 MG	180	TABS	30	DAYS
Nexavar	Sorafenib Tosylate Tab 200 MG (Base Equivalent)	200 MG	120	TABS	30	DAYS
Ninlaro	ixazomib citrate cap	2.3 MG ; 3 MG ; 4 MG	3	CAPS	28	DAYS
Nubeqa	Darolutamide Tab 300 MG	300 MG	120	TABS	30	DAYS
Odomzo	sonidegib phosphate cap	200 MG	30	CAPS	30	DAYS
Onureg	azacitidine tab	200 MG ; 300 MG	14	TABS	28	DAYS
Orgovyx	relugolix tab	120 MG	30	TABS	30	DAYS
Orserdu	elacestrant hydrochloride tab	345 MG	30	TABS	30	DAYS				04-01-2023
Orserdu	elacestrant hydrochloride tab	86 MG	90	TABS	30	DAYS				04-01-2023
Pemazyre	Pemigatinib Tab 13.5 MG	13.5 MG	14	TABS	21	DAYS
Pemazyre	Pemigatinib Tab 4.5 MG	4.5 MG	14	TABS	21	DAYS
Pemazyre	Pemigatinib Tab 9 MG	9 MG	14	TABS	21	DAYS
Piqray 200mg daily dose	Alpelisib Tab Therapy Pack 200 MG Daily Dose	200 MG	28	TABS	28	DAYS
Piqray 250mg daily dose	Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs)	200 MG	56	TABS	28	DAYS
Piqray 300mg daily dose	Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab)	150 MG	56	TABS	28	DAYS
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	21	CAPS	28	DAYS	The quantity limits for Pomalyst are based on dosing for multiple myeloma, which is given daily for 21 days of a 28 day cycle
Qinlock	Ripretinib Tab	50 MG	90	TABS	30	DAYS
Retevmo	Selpercatinib Cap	80 MG	120	CAPS	30	DAYS
Retevmo	Selpercatinib Cap	40 MG	180	CAPS	30	DAYS
Revlimid	Lenalidomide Cap 10 MG	10 MG	30	CAPS	30	DAYS
Revlimid	Lenalidomide Cap 15 MG	15 MG	21	CAPS	28	DAYS	The quantity limits for Revlimid 15 mg & 25 mg capsules are based on dosing for multiple myeloma, which is 25 mg daily for 21 days of a 28 day cycle
Revlimid	Lenalidomide Cap 20 MG	20 ; 20 MG	21	CAPS	21	DAYS
Revlimid	Lenalidomide Cap 25 MG	25 MG	21	CAPS	28	DAYS	The quantity limits for Revlimid 15 mg & 25 mg capsules are based on dosing for multiple myeloma, which is 25 mg daily for 21 days of a 28 day cycle
Revlimid	Lenalidomide Cap 5 MG	5 MG	30	CAPS	30	DAYS
Revlimid	Lenalidomide Caps 2.5 MG	2.5 ; 2.5 MG	30	CAPS	30	DAYS
Rezlidhia	Olutasidenib Cap	150 MG	60	CAPS	30	DAYS				04-01-2023
Rozlytrek	Entrectinib Cap 100 MG	100 MG	30	CAPS	30	DAYS
Rozlytrek	Entrectinib Cap 200 MG	200 MG	90	CAPS	30	DAYS
Rubraca	Rucaparib Camsylate Tab 200 MG (Base Equivalent)	200 MG	120	TABS	30	DAYS
Rubraca	Rucaparib Camsylate Tab 250 MG (Base Equivalent)	250 MG	120	TABS	30	DAYS
Rubraca	Rucaparib Camsylate Tab 300 MG (Base Equivalent)	300 MG	120	TABS	30	DAYS
Rydapt	Midostaurin Cap 25 MG	25 MG	240	CAPS	30	DAYS
Scemblix	Asciminib HCl Tab	20 MG	60	TABS	30	DAYS
Scemblix	Asciminib HCl Tab	40 MG	300	TABS	30	DAYS
Sprycel	Dasatinib Tab	20 MG	90	TABS	30	DAYS
Sprycel	Dasatinib Tab	140 MG	30	TABS	30	DAYS
Sprycel	Dasatinib Tab	70 MG	30	TABS	30	DAYS
Sprycel	Dasatinib Tab	80 MG	30	TABS	30	DAYS
Sprycel	Dasatinib Tab	100 MG	30	TABS	30	DAYS
Sprycel	Dasatinib Tab	50 MG	30	TABS	30	DAYS
Stivarga	regorafenib tab	40 MG	84	TABS	28	DAYS	based 160 mg daily for 21 days of a 28 day cycle
Sutent	Sunitinib Malate Cap 12.5 MG (Base Equivalent)	12.5 MG	90