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Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary Pt. 2

Policy Number: PH-10691

 

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

CLIENT SUMMARY – PRIOR AUTHORIZATION Continued

Mekinist

trametinib dimethyl sulfoxide tab

0.5 MG ; 2 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Mektovi

binimetinib tab

15 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nerlynx

neratinib maleate tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nerlynx

neratinib maleate tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nexavar

sorafenib tosylate tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ninlaro

ixazomib citrate cap

2.3 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nubeqa

darolutamide tab

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Odomzo

sonidegib phosphate cap

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Onureg

azacitidine tab

200 MG ; 300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Orgovyx

relugolix tab

120 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Orserdu

elacestrant hydrochloride tab

345 MG ; 86 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pemazyre

pemigatinib tab

13.5 MG ; 4.5 MG ; 9 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Piqray 200mg daily dose ; Piqray 250mg daily dose ; Piqray 300mg daily dose

alpelisib tab pack  ; alpelisib tab therapy pack

150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pomalyst

pomalidomide cap

1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pomalyst

pomalidomide cap

1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qinlock

ripretinib tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qinlock

ripretinib tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Retevmo

selpercatinib cap

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Retevmo

selpercatinib cap

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

lenalidomide cap  ; lenalidomide caps

10 MG ; 15 MG ; 2.5  ; 2.5 MG ; 20  ; 20 MG ; 25 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rezlidhia

olutasidenib cap

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rozlytrek

entrectinib cap

100 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rubraca

rucaparib camsylate tab

200 MG ; 250 MG ; 300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rydapt

midostaurin cap

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

dasatinib tab

100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Stivarga

regorafenib tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sutent

sunitinib malate cap

12.5 MG ; 25 MG ; 37.5 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tabrecta

capmatinib hcl tab

150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tabrecta

capmatinib hcl tab

150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tafinlar

dabrafenib mesylate cap

50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tagrisso

osimertinib mesylate tab

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tagrisso

osimertinib mesylate tab

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Talzenna

talazoparib tosylate cap

0.25 MG ; 0.5 MG ; 0.75 MG ; 1 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tarceva

erlotinib hcl tab

100 MG ; 150 MG ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tarceva

erlotinib hcl tab

100 MG ; 150 MG ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Targretin

bexarotene cap

75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Targretin

Bexarotene Gel 1%

1 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tasigna

nilotinib hcl cap

150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tazverik

tazemetostat hbr tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Temodar

temozolomide cap

100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Thalomid

thalidomide cap

100 MG ; 150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tibsovo

ivosidenib tab

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

infigratinib phos cap pack  ; infigratinib phos cap ther pack

100 MG ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tukysa

tucatinib tab

150 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tukysa

tucatinib tab

150 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Turalio

pexidartinib hcl cap

125 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Turalio

pexidartinib hcl cap

125 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tykerb

lapatinib ditosylate tab

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tykerb

lapatinib ditosylate tab

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ukoniq

umbralisib tosylate tab

200 MG

Venclexta

venetoclax tab

10 MG ; 100 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venclexta starting pack

venetoclax tab therapy starter pack

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Verzenio

abemaciclib tab

100 MG ; 150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vitrakvi

larotrectinib sulfate cap

100 MG ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vitrakvi

larotrectinib sulfate oral soln

20 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vizimpro

dacomitinib tab

15 MG ; 30 MG ; 45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vizimpro

dacomitinib tab

15 MG ; 30 MG ; 45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vonjo

pacritinib citrate cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Votrient

pazopanib hcl tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Votrient

pazopanib hcl tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Welireg

belzutifan tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xalkori

crizotinib cap

200 MG ; 250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xalkori

crizotinib cap

200 MG ; 250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xeloda

capecitabine tab

150 MG ; 500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xospata

gilteritinib fumarate tablet

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xospata

gilteritinib fumarate tablet

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

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

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xtandi

enzalutamide cap

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xtandi

enzalutamide tab

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Yonsa

abiraterone acetate tab

125 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zejula

niraparib tosylate cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zelboraf

vemurafenib tab

240 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zolinza

vorinostat cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zydelig

idelalisib tab

100 MG ; 150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zykadia

ceritinib tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zykadia

ceritinib tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zytiga

abiraterone acetate tab

250 MG ; 500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Besremi

ropeginterferon alfa-

500 MCG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bosulif

bosutinib tab

100 MG ; 400 MG ; 500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Gleevec

imatinib mesylate tab

100 MG ; 400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iclusig

ponatinib hcl tab

10 MG ; 15 MG ; 30 MG ; 45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Scemblix

asciminib hcl tab

20 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

dasatinib tab

100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tasigna

nilotinib hcl cap

150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Afinitor

everolimus tab

10 MG ; 2.5 MG ; 5 MG ; 7.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Afinitor disperz

Everolimus Tab for Oral Susp 2 MG

2 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Afinitor disperz

Everolimus Tab for Oral Susp 3 MG

3 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Afinitor disperz

Everolimus Tab for Oral Susp 5 MG

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alecensa

alectinib hcl cap

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alunbrig

Brigatinib Tab

180 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alunbrig

Brigatinib Tab

90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alunbrig

Brigatinib Tab

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Alunbrig

Brigatinib Tab Initiation Therapy Pack

90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ayvakit

avapritinib tab

100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Balversa

Erdafitinib Tab 3 MG

3 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Balversa

Erdafitinib Tab 4 MG

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Balversa

Erdafitinib Tab 5 MG

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Besremi

Ropeginterferon alfa-

500 MCG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bosulif

Bosutinib Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bosulif

bosutinib tab

100 MG ; 400 MG ; 500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Braftovi

encorafenib cap

75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Brukinsa

Zanubrutinib Cap

80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cabometyx

Cabozantinib S-Malate Tab

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cabometyx

Cabozantinib S-Malate Tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cabometyx

Cabozantinib S-Malate Tab

60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Calquence

acalabrutinib cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Calquence

acalabrutinib maleate tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Caprelsa

Vandetanib Tab

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Caprelsa

Vandetanib Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cometriq

Cabozantinib S-Mal Cap

3 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cometriq

Cabozantinib S-Mal Cap

80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cometriq

Cabozantinib S-Malate Cap

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Copiktra

duvelisib cap

15 MG ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cotellic

cobimetinib fumarate tab

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Daurismo

Glasdegib Maleate Tab 100 MG (Base Equivalent)

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Daurismo

Glasdegib Maleate Tab 25 MG (Base Equivalent)

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Erivedge

Vismodegib Cap 150 MG

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Erleada

apalutamide tab

240 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Erleada

Apalutamide Tab 60 MG

60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Exkivity

Mobocertinib Succinate Cap

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Farydak

panobinostat lactate cap

10 MG ; 15 MG ; 20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fotivda

Tivozanib HCl Cap

0.89 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fotivda

Tivozanib HCl Cap

1.34 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Gavreto

pralsetinib cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Gilotrif

afatinib dimaleate tab

20 MG ; 30 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Gleevec

Imatinib Mesylate Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Gleevec

Imatinib Mesylate Tab

400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ibrance

palbociclib cap  ; palbociclib tab

100 MG ; 125 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iclusig

Ponatinib HCl Tab

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iclusig

Ponatinib HCl Tab

15 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iclusig

Ponatinib HCl Tab

45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iclusig

Ponatinib HCl Tab

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Idhifa

Enasidenib Mesylate Tab 100 MG (Base Equivalent)

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Idhifa

Enasidenib Mesylate Tab 50 MG (Base Equivalent)

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imbruvica

Ibrutinib Cap

70 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imbruvica

Ibrutinib Cap

140 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imbruvica

Ibrutinib Oral Susp

70 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Imbruvica

ibrutinib tab

140 MG ; 280 MG ; 420 MG ; 560 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Inlyta

Axitinib Tab

1 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Inlyta

Axitinib Tab

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Inqovi

Decitabine-Cedazuridine Tab  ; decitabine-cedazuridine tab

0  ; 35 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Inrebic

Fedratinib HCl Cap 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Iressa

gefitinib tab

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Jakafi

ruxolitinib phosphate tab

10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Jaypirca

pirtobrutinib tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Jaypirca

pirtobrutinib tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali

Ribociclib Succinate Tab Pack 200 MG Daily Dose

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali

Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab)

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali

Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab)

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali femara 200 dose

Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali femara 400 dose

Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Kisqali femara 600 dose

Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Koselugo

Selumetinib Sulfate Cap 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Koselugo

Selumetinib Sulfate Cap 25 MG

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Krazati

Adagrasib Tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 10 mg daily dose

Lenvatinib Cap Therapy Pack

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 12mg daily dose

Lenvatinib Cap Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 14 mg daily dose

Lenvatinib Cap Therapy Pack

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 18 mg daily dose

Lenvatinib Cap Ther Pack

10 2 x 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 20 mg daily dose

Lenvatinib Cap Therapy Pack

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 24 mg daily dose

Lenvatinib Cap Ther Pack

2 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 4 mg daily dose

Lenvatinib Cap Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lenvima 8 mg daily dose

Lenvatinib Cap Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lonsurf

Trifluridine-Tipiracil Tab 15-6.14 MG

15 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lonsurf

Trifluridine-Tipiracil Tab 20-8.19 MG

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lorbrena

Lorlatinib Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lorbrena

Lorlatinib Tab

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lumakras

sotorasib tab

320

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lumakras

Sotorasib Tab

120 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lynparza

olaparib tab

100 MG ; 150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lytgobi

Futibatinib Tab Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lytgobi

Futibatinib Tab Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lytgobi

Futibatinib Tab Therapy Pack

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Mekinist

Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)

0.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Mekinist

Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)

2 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Mektovi

binimetinib tab

15 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nerlynx

Neratinib Maleate Tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nexavar

Sorafenib Tosylate Tab 200 MG (Base Equivalent)

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ninlaro

ixazomib citrate cap

2.3 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Nubeqa

Darolutamide Tab 300 MG

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Odomzo

sonidegib phosphate cap

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Onureg

azacitidine tab

200 MG ; 300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Orgovyx

relugolix tab

120 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Orserdu

elacestrant hydrochloride tab

345 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Orserdu

elacestrant hydrochloride tab

86 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pemazyre

Pemigatinib Tab 13.5 MG

13.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pemazyre

Pemigatinib Tab 4.5 MG

4.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pemazyre

Pemigatinib Tab 9 MG

9 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Piqray 200mg daily dose

Alpelisib Tab Therapy Pack 200 MG Daily Dose

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Piqray 250mg daily dose

Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs)

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Piqray 300mg daily dose

Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab)

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pomalyst

pomalidomide cap

1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Qinlock

Ripretinib Tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Retevmo

Selpercatinib Cap

80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Retevmo

Selpercatinib Cap

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Cap 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Cap 15 MG

15 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Cap 20 MG

20  ; 20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Cap 25 MG

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Cap 5 MG

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Revlimid

Lenalidomide Caps 2.5 MG

2.5  ; 2.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rezlidhia

Olutasidenib Cap

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rozlytrek

Entrectinib Cap 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rozlytrek

Entrectinib Cap 200 MG

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rubraca

Rucaparib Camsylate Tab 200 MG (Base Equivalent)

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rubraca

Rucaparib Camsylate Tab 250 MG (Base Equivalent)

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rubraca

Rucaparib Camsylate Tab 300 MG (Base Equivalent)

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rydapt

Midostaurin Cap 25 MG

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Scemblix

Asciminib HCl Tab

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Scemblix

Asciminib HCl Tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

140 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

70 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sprycel

Dasatinib Tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Stivarga

regorafenib tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sutent

Sunitinib Malate Cap 12.5 MG (Base Equivalent)

12.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sutent

Sunitinib Malate Cap 25 MG (Base Equivalent)

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sutent

Sunitinib Malate Cap 37.5 MG (Base Equivalent)

37.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sutent

Sunitinib Malate Cap 50 MG (Base Equivalent)

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tabrecta

capmatinib hcl tab

150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tafinlar

dabrafenib mesylate cap

50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tagrisso

osimertinib mesylate tab

40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Talzenna

Talazoparib Tosylate Cap

0.75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Talzenna

Talazoparib Tosylate Cap

0.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Talzenna

Talazoparib Tosylate Cap 0.25 MG (Base Equivalent)

0.25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Talzenna

Talazoparib Tosylate Cap 1 MG (Base Equivalent)

1 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tarceva

Erlotinib HCl Tab

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tarceva

Erlotinib HCl Tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tarceva

Erlotinib HCl Tab

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tasigna

nilotinib hcl cap

150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tazverik

tazemetostat hbr tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Thalomid

Thalidomide Cap 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Thalomid

Thalidomide Cap 150 MG

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Thalomid

Thalidomide Cap 200 MG

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Thalomid

Thalidomide Cap 50 MG

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tibsovo

Ivosidenib Tab 250 MG

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

Infigratinib Phos Cap Pack

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

Infigratinib Phos Cap Pack

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

Infigratinib Phos Cap Ther Pack

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

Infigratinib Phos Cap Ther Pack

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Truseltiq

Infigratinib Phos Cap Ther Pack

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tukysa

Tucatinib Tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tukysa

Tucatinib Tab

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Turalio

Pexidartinib HCl Cap

125 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Turalio

Pexidartinib HCl Cap

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Tykerb

Lapatinib Ditosylate Tab

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Ukoniq

umbralisib tosylate tab

200 MG

Venclexta

Venetoclax Tab 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venclexta

Venetoclax Tab 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venclexta

Venetoclax Tab 50 MG

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venclexta starting pack

Venetoclax Tab Therapy Starter Pack 10 & 50 & 100 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Verzenio

abemaciclib tab

100 MG ; 150 MG ; 200 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vitrakvi

Larotrectinib Sulfate Cap 100 MG (Base Equivalent)

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vitrakvi

Larotrectinib Sulfate Cap 25 MG (Base Equivalent)

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vitrakvi

Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent)

20 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vizimpro

dacomitinib tab

15 MG ; 30 MG ; 45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vonjo

Pacritinib Citrate Cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Votrient

Pazopanib HCl Tab

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Welireg

Belzutifan Tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xalkori

crizotinib cap

200 MG ; 250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xospata

Gilteritinib Fumarate Tablet

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio

Selinexor Tab Therapy Pack

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio

Selinexor Tab Therapy Pack

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio

Selinexor Tab Therapy Pack

60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio

Selinexor Tab Therapy Pack

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio

Selinexor Tab Therapy Pack

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 100 mg once weekly

Selinexor Tab Therapy Pack 20 MG (100 MG Once Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 40 mg once weekly

Selinexor Tab Therapy Pack 20 MG (40 MG Once Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 40 mg twice weekly

Selinexor Tab Therapy Pack 20 MG (40 MG Twice Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 60 mg once weekly

Selinexor Tab Therapy Pack 20 MG (60 MG Once Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 60 mg twice weekly

Selinexor Tab Therapy Pack 20 MG (60 MG Twice Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 80 mg once weekly

Selinexor Tab Therapy Pack 20 MG (80 MG Once Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xpovio 80 mg twice weekly

Selinexor Tab Therapy Pack 20 MG (80 MG Twice Weekly)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xtandi

enzalutamide cap

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xtandi

Enzalutamide Tab

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Xtandi

Enzalutamide Tab

80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Yonsa

abiraterone acetate tab 125 mg

125 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zejula

niraparib tosylate cap

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zelboraf

Vemurafenib Tab 240 MG

240 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zolinza

Vorinostat Cap 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zydelig

idelalisib tab

100 MG ; 150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zykadia

ceritinib tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zytiga

Abiraterone Acetate Tab 250 MG

250 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zytiga

Abiraterone Acetate Tab 500 MG

500 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

PREFERRED AGENTS

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

PA

QL

Preferred agent options are as follows.

Indication(s)

Number of Preferred Required

Preferred Agent(s)

Non-Preferred Agent(s)

Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia in chronic phase

1 preferred agent

Imatinib (generic), Sprycel

Bosulif, Tasigna

Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase with the T315I mutation

1 preferred agent

Iclusig

Scemblix

Polycythemia Vera

1 preferred agent

Peginterferon*

BESREMi

NOTE: brand Gleevec to be managed through generic before brand requirement

*- preferred agent targeted in another utilization management program and requires Prior Authorization

 

Initial Evaluation

Target Agent(s) will be approved when ALL of the following are met:

  1. ONE of the following:
    1. Information has been provided that indicates the patient is currently being treated with the requested agent within the past 180 days OR
    2. The prescriber states the patient is being treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
    3. ALL of the following:
      1. ONE of the following:
        1. The patient has an FDA approved indication for the requested agent OR
        2. The patient has an indication that is supported by NCCN 1 or 2A recommended use, AHFS, or DrugDex level of evidence of 1 or 2A [i.e., this indication must be supported by ALL requirements in the compendia (e.g., performance status, disease severity, previous failures, monotherapy vs combination therapy, etc.)] for the requested agent AND 
      2. ONE of the following:
        1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
        2. The prescriber has provided information in support of using the requested agent for the patient’s age for the requested indication AND
      3. ONE of the following:
        1. ALL of the following:
          1. The requested indication requires genetic/specific diagnostic testing per FDA labeling or compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested agent AND
          2. Genetic/specific diagnostic testing has been completed AND
          3. The results of the genetic/specific diagnostic testing indicate therapy with the requested agent is appropriate OR
        2. The requested indication does NOT require specific genetic/diagnostic testing per FDA labeling or supported by compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested agent AND
      4. ONE of the following:
        1. The requested agent is being used as monotherapy AND is approved for use as monotherapy in the FDA labeling or compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested indication OR
        2. The requested agent will be used as combination therapy with all agent(s) and/or treatments (e.g., radiation) listed for concomitant use in the FDA labeling or compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested indication AND
      5. ONE of the following:
        1. The requested agent will be used as a first-line agent AND is FDA labeled or supported by compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) as a first-line agent for the requested indication OR
        2. The patient has tried and had an inadequate response to the appropriate number and type(s) of prerequisite agent(s) listed in the FDA labeling or compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested indication OR
        3. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to the appropriate number and type(s) of prerequisite agent(s) listed in the FDA labeling or compendia (NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A) for the requested indication AND
      6. ONE of the following: 

Indication(s)

Number of Preferred Required

Preferred Agent(s)

Non-Preferred Agent(s)

Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia in chronic phase

1 preferred agent

Imatinib (generic), Sprycel

Bosulif, Tasigna

Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase with the T315I mutation

1 preferred agent

Iclusig

Scemblix

Polycythemia Vera

1 preferred agent

Peginterferon

BESREMi

        1. The requested agent is a preferred agent for the requested indication OR
        2. The requested agent is a non-preferred agent for the requested indication AND ONE of the following:
          1. The patient’s medication history indicates use of a preferred agent for the requested indication OR
          2. The patient has an intolerance or hypersensitivity to a preferred agent(s) for the requested indication OR
          3. The patient has an FDA labeled contraindication to ALL preferred agent(s) for the requested indication OR
          4. BOTH of the following:
            1. NCCN does NOT specify the plan preferred agent(s) as a preferred regimen for the requested indication AND
            2. NCCN specifies the requested agent as a preferred regimen for the requested indication OR
          5. The prescriber has provided information in support of use of the non-preferred agent over the preferred agent(s) for the requested indication OR
          6. If the requested agent is Bosulif or Tasigna for CML, the patient has been previously treated with either Bosulif OR Tasigna for the requested indication AND
      2. If the requested agent is Imbruvica 140 mg or 280 mg tablets, ONE of the following:
        1. The patient has tried and had an inadequate response to Imbruvica 140 mg capsules OR
        2. The patient has an intolerance or hypersensitivity to Imbruvica capsules that is not expected to occur with Imbruvica tablets OR
        3. The patient has an FDA labeled contraindication to Imbruvica capsules that is not expected to occur with Imbruvica tablets AND
      3. If the requested agent is Zytiga/abiraterone 500 mg, ONE of the following:
        1. The patient has tried and had an inadequate response to generic abiraterone 250 mg tablets OR
        2. The patient has an intolerance or hypersensitivity to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent OR
        3. The patient has an FDA labeled contraindication to generic abiraterone 250 mg tablets that is not expected to occur with the requested agent AND
  2. If the requested agent is for one of the following brand agents with a generic equivalent (listed below), then ONE of the following:

Brand

Generic Equivalent

Afinitor

everolimus

Afinitor Disperz

everolimus

Gleevec

imatinib

Sutent

sunitinib

Tarceva

erlotinib

Targretin

bexarotene

Temodar

temozolomide

Tykerb

lapatinib

Xeloda

capecitabine

Zytiga

abiraterone

    1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the requested brand agent OR
    2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the requested brand agent OR
    3. The prescriber has provided information to support the use of the requested brand agent over the generic equivalent AND
  2. The patient does not have any FDA labeled contraindications to the requested agent AND
  3. The patient does not have any FDA labeled limitation(s) of use that is otherwise not supported in NCCN to the requested agent

Length of Approval:  Up to 3 months for dose titration requests over the program quantity limit and Vitrakvi; Up to 12 months for all other requests, approve starter packs and loading doses where appropriate and maintenance dose for the remainder of the authorization

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

 

Renewal Evaluation

Target Agent(s) will be approved when ALL of the following are met:

  1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  2. ONE of the following:
    1. The requested agent is Vitrakvi AND the patient has experienced clinical benefit (i.e., partial response, complete response, or stable disease) with the requested agent OR
    2. The requested agent is NOT Vitrakvi AND
    3. If the requested agent is for one of the following brand agents with a generic equivalent (listed below), then ONE of the following: 

Brand

Generic Equivalent

Afinitor

everolimus

Afinitor Disperz

everolimus

Gleevec

imatinib

Sutent

sunitinib

Tarceva

erlotinib

Targretin

bexarotene

Temodar

temozolomide

Tykerb

lapatinib

Xeloda

capecitabine

Zytiga

abiraterone
      1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the requested brand agent OR
      2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the requested brand agent OR
      3. The prescriber has provided information to support the use of the requested brand agent over the generic equivalent AND
  2. The patient does not have any FDA labeled contraindications to the requested agent AND
  3. The patient does not have any FDA labeled limitation(s) of use that is otherwise not supported in NCCN to the requested agent

Length of Approval:  Up to 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

FDA Companion Diagnostics:  https://www.fda.gov/medical-devices/vitro-diagnostics/list-cleared-or-approved-companion-diagnostic-devices-vitro-and-imaging-tools

 

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

QL with PA

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. ALL of the following:
    1. The requested quantity (dose) is greater than the program quantity limit AND
    2. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
    3. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit OR
  3. ALL of the following:
    1. The requested quantity (dose) is greater than the program quantity limit AND
    2. The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
    3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: Up to 3 months for dose titration requests over the program quantity limit and Vitrakvi; Up to 12 months for all other requests, approve starter packs/loading doses where appropriate and maintenance doses for the remainder of the authorization

 

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

Commercial _ PS _ Self-Administered Oncology Agents Prior Authorization with Quantity Limit _ProgSum_ 7/1/2023