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ph-1069

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

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
10-01-2024	05-01-2001

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

CLINICAL RATIONALE

Indications

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 (3-121)

Agent(s)	Contraindication(s)
Afinitor/Afinitor Disperz (everolimus)	Clinically significant hypersensitivity to everolimus, to other rapamycin derivatives
Akeega (niraparib and abiraterone)	None
Alecensa (alectinib)	None
Alunbrig (brigatinib)	None
Augtyro (repotrectinib)	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)	History of 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
Fotivda (tivozanib)	None
Fruzaqla (fruquintinib)	None
Gavreto (pralsetinib)	None
Gilotrif (afatinib)	None
Gleevec (imatinib)	None
Hycamtin (topotecan)	History of 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
Iwilfin (eflornithine)	None
Jakafi (ruxolitinib)	None
Jaypirca (pirtobrutinib)	None
Kisqali (ribociclib)	None
Kisqali Femara Pack (ribociclib and letrozole co-packaged)	Known 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 any other component of Nexavar Use in combination with carboplatin and paclitaxel in patients with squamous cell lung cancer
Ninlaro (ixazomib)	None
Nubeqa (darolutamide)	None
Odomzo (sonidegib)	None
Ojjaara (momelotinib)	None
Ogsiveo (nirogacestat)	None
Ojemda (tovorafenib)	None
Onureg (azacitidine)	Known severe hypersensitivity to azacitidine or its components
Orgovyx (relugolix)	Known severe hypersensitivity to relugolix or to any of the product components
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) Hypersensitivity to temozolomide or any other ingredients in Temodar
Tepmetko (tepotinib)	None
Thalomid (thalidomide)	Pregnancy Demonstrated hypersensitivity to thalidomide or its components
Tibsovo (ivosidenib)	None
Tretinoin (oral)	Known hypersensitivity to tretinoin, any of its components, or other retinoids
Truqap (capivasertib)	Severe hypersensitivity to Truqap or any of its components
Truseltiq (infigratinib)	None
Tukysa (tucatinib)	None
Turalio (pexidartinib)	None
Tykerb (lapatinib)	Known hypersensitivity to lapatinib or its components
Vanflyta (quizartinib)	Contraindicated in patients with severe hypokalemia, severe hypomagnesemia, long QT syndrome, or in patients with a history of ventricular arrhythmias or torsades de pointes
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 hypersensitivity to fluorouracil or capecitabine
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 to idelalisib, including anaphylaxis and toxic epidermal necrolysis with any drug
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 Pharmaceuticals Corporation. February 2022.
4	Alecensa prescribing information. Genentech, Inc. September 2021.
5	Alunbrig prescribing information. Takeda Pharmaceuticals America, Inc. February 2022.
6	Ayvakit prescribing information. Blueprint Medicines Corp. March 2023.
7	Balversa prescribing information. Janssen Products, LP. January 2023.
8	BESREMi prescribing information. Pharmaessentia USA. November 2021.
9	Bosulif prescribing information. Pfizer Laboratories Div of Pfizer Inc. September 2023.
10	Braftovi prescribing information. Array BioPharma Inc. February 2022.
11	Brukinsa prescribing information. BeiGene, USA, Inc. April 2023.
12	Cabometyx prescribing information. Exelixis, Inc. January 2023.
13	Calquence prescribing information. AstraZeneca Pharmaceuticals LP. March 2022.
14	Caprelsa prescribing information. Genzyme Corporation. March 2022.
15	Cometriq prescribing information. Exelixis, Inc. February 2022.
16	Copiktra prescribing information. Secura Bio, Inc. February 2022.
17	Cotellic prescribing information. Genentech, Inc. November 2022.
18	Daurismo prescribing information. Pfizer Laboratories Div Pfizer Inc. March 2023.
19	Erivedge prescribing information. Genentech, Inc. March 2023.
20	Erleada prescribing information. Janssen Products, LP. February 2023.
21	Reference no longer used.
22	Reference no longer used
23	Fotivda prescribing information. Aveo Pharmaceuticals, Inc. March 2021.
24	Gavreto prescribing information. Genentech Inc. February 2022.
25	Gilotrif prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. April 2022.
26	Gleevec prescribing information. Novartis Pharmaceuticals Corporation. August 2022.
27	Hycamtin prescribing Information. Novartis Pharmaceuticals Corporation. September 2018.
28	Ibrance prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2022.
29	Iclusig prescribing information. Takeda Pharmaceuticals America, Inc. February 2022.
30	Idhifa prescribing information. Celgene Corporation. August 2022.
31	Imbruvica prescribing information. Pharmacyclics, Inc. August 2022.
32	Inlyta prescribing information. Pfizer. Laboratories Div Pfizer Inc. September 2022.
33	Inqovi prescribing information. Taiho Pharmaceutical Co., LTD. March 2022.
34	Inrebic prescribing information. Celgene Corporation. October 2022.
35	Iressa prescribing information. AstraZeneca Pharmaceuticals LP. February 2023.
36	Jakafi prescribing information. Incyte Corporation. January 2023.
37	Kisqali Femara Pack prescribing information. Novartis Pharmaceuticals Corporation. October 2022.
38	Kisqali prescribing information. Novartis Pharmaceuticals Corporation. October 2022.
39	Koselugo prescribing information. AstraZeneca Pharmaceuticals LP. December 2021.
40	Lenvima prescribing information. Eisai Inc. November 2022.
41	Lonsurf prescribing information. Taiho Oncology, Inc. January 2020.
42	Lorbrena prescribing information. Pfizer Laboratories Div Pfizer Inc. March 2021.
43	Lumakras prescribing information. Amgen Inc. January 2023.
44	Lynparza tablets prescribing information. AstraZeneca Pharmaceuticals LP. October 2022.
45	Lysodren prescribing information. HRA Pharma Rare Diseases. June 2021.
46	Matulane prescribing information. Leadiant Biosciences. August 2018.
47	Mekinist prescribing information. Novartis Pharmaceuticals Corporation. March 2023.
48	Mektovi prescribing information. Array BioPharma Inc. November 2020.
49	Nerlynx prescribing information. Puma Biotech. March 2022.
50	Nexavar prescribing information. Bayer HealthCare Pharmaceuticals Inc. May 2021.
51	Ninlaro prescribing information. Takeda Pharmaceuticals America, Inc. November 2022.
52	Nubeqa prescribing information. Bayer HealthCare Pharmaceuticals Inc. August 2022.
53	Odomzo prescribing information. Sun Pharmaceutical Industries, Inc. May 2019.
54	Onureg prescribing information. Celgene Corporation. October 2022.
55	Orgovyx prescribing information. Myovant Sciences, Inc. March 2023.
56	Pemazyre prescribing information. Incyte Corporation. August 2022.
57	Piqray prescribing information. Novartis Pharmaceuticals Corp. May 2022.
58	Pomalyst prescribing information. Celgene Corporation. March 2023.
59	Qinlock prescribing information. Deciphera Pharmaceuticals, LLC. December 2022.
60	Retevmo prescribing information. Eli Lilly and Company. September 2022.
61	Revlimid prescribing information. Celgene Corporation. March 2023.
62	Rozlytrek prescribing information. Genentech USA, Inc. October 2023.
63	Rubraca prescribing information. Clovis Oncology, Inc. December 2022.
64	Rydapt prescribing information. Novartis Pharmaceuticals Corporation. November 2021.
65	Scemblix prescribing information. Novartis Pharmsceuticals Corporation. April 2024.
66	Sprycel prescribing information. E.R. Squibb & Sons, L.L.C. February 2023.
67	Stivarga prescribing information. Bayer Healthcare Pharmaceuticals Inc. December 2020.
68	Sutent prescribing information. Pfizer Laboratories Div Pfizer Inc. August 2021.
69	Tabrecta prescribing information. Novartis Pharmaceuticals Corp. March 2023.
70	Tafinlar prescribing information. Novartis Pharmaceuticals Corporation. March 2023.
71	Tagrisso prescribing information. AstraZeneca Pharmaceuticals LP. October 2022.
72	Talzenna prescribing information. Pfizer Laboratories Div Pfizer Inc. June 2023.
73	Tarceva prescribing information. Genentech inc. October 2016.
74	Targretin capsule prescribing information. Bausch Health US, LLC. April 2020.
75	Targretin gel prescribing information. Bausch Health US, LLC. February 2020.
76	Tasigna prescribing information. Novartis Pharmaceuticals Corporation. September 2021.
77	Tazverik prescribing information. Epizyme Inc. July 2020.
78	Temodar prescribing Information. Merck Sharp & Dohme Corp. November 2022.
79	Tepmetko prescribing information. EMD Serono, Inc. March 2023.
80	Thalomid prescribing information. Celgene Corporation. March 2023.
81	Tibsovo prescribing information. ServierPharmaceutical LLC, Inc. May 2022.
82	Tretinoin prescribing information. Glenmark Pharmaceuticals, Inc, USA. April 2023.
83	Truseltiq prescribing information. QED Therapeutics Inc. May 2021.
84	Tukysa prescribing information. Seagen Inc. January 2023.
85	Turalio prescribing information. Daiichi Sankyo, Inc. December 2022.
86	Tykerb prescribing information. Novartis Pharmaceuticals Corporation. March 2022.
87	Reference is no longer used
88	Venclexta prescribing information. AbbVie Inc. June 2022.
89	Verzenio prescribing information. Eli Lilly and Company. March 2023.
90	Vitrakvi prescribing information. Bayer HealthCare Pharmaceuticals Inc. December 2022.
91	Vizimpro prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2020.
92	Votrient prescribing information. Novartis Pharmaceuticals Corporation. December 2021.
93	Welireg prescribing information. Merck Sharp & Dohme LLC. May 2022.
94	Xalkori prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2023.
95	Xeloda prescribing information. H2-Pharma, LLC. April 2023.
96	Xospata prescribing information. Astellas Pharma US, Inc. January 2022.
97	Xpovio prescribing information. Karyopharm Therapeutics Inc. July 2022.
98	Xtandi prescribing information. Astellas Pharma US, Inc. September 2022.
99	Yonsa prescribing information. Sun Pharmaceuticals Industries, Inc. March 2022.
100	Zejula capsule prescribing information. GSK LLC. April 2023.
101	Zelboraf prescribing information. Genentech, Inc. May 2020.
102	Zolinza prescribing information. Merck Sharp & Dohme LLC. July 2022.
103	Zydelig prescribing information. Gilead Sciences, Inc. February 2022.
104	Zykadia prescribing information. Novartis Pharmaceuticals Corporation. 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. Rigel Pharmaceuticals, 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.
112	Zejula tablet prescribing information. GlaxoSmithKline. April 2023.
113	Vanflyta prescribing information. Daiichi Sankyo Inc. July 2023.
114	Akeega prescribing information. Janssen Biotech, Inc. August 2023.
115	Ojjaara prescribing information. GlaxoSmithKline LLC. September 2023.
116	Fruzaqla prescribing information. Takeda Pharmaceuticals U.S.A., Inc. November 2023
117	Truqap prescribing information. AstraZeneca Pharmaceuticals LP. November 2023.
118	Augtyro prescribing information. Bristol-Myers Squibb Company. November 2023.
119	Ogsiveo prescribing information. SpringWorks Therapeutics, Inc. November 2023.
120	Iwilfin prescribing information.US Worldmeds (USWM), LCC. December 2023.
121	Ojemda prescribing information. Day One Biopharmaceuticals, Inc. April 2024.

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Target Brand Agent(s)	Target Generic Agent(s)	Strength	Targeted MSC	Available MSC	Final Age Limit	Preferred Status

			M ; N ; O ; Y
Verzenio	abemaciclib tab	100 MG ; 150 MG ; 200 MG ; 50 MG	M ; N ; O ; Y	N
Yonsa	abiraterone acetate micronized tab	125 MG	M ; N ; O ; Y	N
Zytiga	abiraterone acetate tab	250 ; 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
Krazati	adagrasib tab	200 MG	M ; N ; O ; Y	N
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 & 50 MG ; 200 MG	M ; N ; O ; Y	N
Erleada	apalutamide tab	240 MG ; 60 MG	M ; N ; O ; Y	N
Scemblix	asciminib hcl tab	100 MG ; 20 MG ; 40 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 cap ; bosutinib tab	100 MG ; 400 MG ; 50 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 & 180 MG ; 90 MG	M ; N ; O ; Y	N
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 & 180 MG	M ; N ; O ; Y	N
Cometriq	cabozantinib s-mal cap ; cabozantinib s-malate cap	20 MG ; 3 x 20 MG & 80 MG ; 80 & 20 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
Truqap	capivasertib tab	160 MG ; 200 MG	M ; N ; O ; Y	N
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 ; crizotinib cap sprinkle	150 MG ; 20 MG ; 200 MG ; 250 MG ; 50 MG	M ; N ; O ; Y	N
Tafinlar	dabrafenib mesylate cap	50 MG ; 75 MG	M ; N ; O ; Y	N
Tafinlar	dabrafenib mesylate tab for oral susp	10 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	35-100 MG	M ; N ; O ; Y	N
Inqovi	decitabine-cedazuridine tab	35-100 MG	M ; N ; O ; Y	N
Copiktra	duvelisib cap	15 MG ; 25 MG	M ; N ; O ; Y	N
Iwilfin	eflornithine hcl tab	192 MG	M ; N ; O ; Y	N
Orserdu	elacestrant hydrochloride tab	345 MG ; 86 MG	M ; N ; O ; Y	N
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
Rozlytrek	entrectinib pellet pack	50 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	O ; Y
Tarceva	erlotinib hcl tab	100 MG ; 150 MG ; 25 MG	M ; N ; O ; Y	O ; Y
Afinitor ; Torpenz	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	M ; N ; O ; Y	O ; Y
Afinitor ; Torpenz	Everolimus Tab 10 MG	10 MG	M ; N ; O ; Y	O ; Y
Afinitor ; Torpenz	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
Fruzaqla	fruquintinib cap	1 MG ; 5 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	O ; Y
Iressa	gefitinib tab	250 MG	M ; N ; O ; Y	O ; Y
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
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 & 25 MG ; 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	O ; Y
Tykerb	lapatinib ditosylate tab	250 MG	M ; N ; O ; Y	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 MG ; 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 & 4 MG ; 10 MG ; 10 MG & 2 x 4 MG ; 2 x 10 MG & 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
Ojjaara	momelotinib dihydrochloride tab	100 MG ; 150 MG ; 200 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
Zejula	niraparib tosylate tab	100 MG ; 200 MG ; 300 MG	M ; N ; O ; Y	N
Akeega	niraparib tosylate-abiraterone acetate tab	100-500 MG ; 50-500 MG	M ; N ; O ; Y	N
Ogsiveo	nirogacestat hydrobromide tab	100 MG ; 150 MG ; 50 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
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
Votrient	pazopanib hcl tab	200 MG	M ; N ; O ; Y	O ; Y
Votrient	pazopanib hcl tab	200 MG	M ; N ; O ; Y	O ; Y
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
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	N
Gavreto	pralsetinib cap	100 MG	M ; N ; O ; Y	M ; N
Gavreto	pralsetinib cap	100 MG	M ; N ; O ; Y	M ; N
Matulane	procarbazine hcl cap	50 MG	M ; N ; O ; Y	N
Vanflyta	quizartinib dihydrochloride tab	17.7 MG ; 26.5 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
Augtyro	repotrectinib cap	40 MG	M ; N ; O ; Y	N
Kisqali femara 200 dose ; Kisqali femara 400 dose ; Kisqali femara 600 dose	ribociclib	200 & 2.5 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
Besremi	ropeginterferon alfa-	500 MCG/ML	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 60 mg twice 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 MG	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	0.1 MG ; 0.25 MG ; 0.35 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
Ojemda	tovorafenib for oral susp ; tovorafenib tab	100 MG ; 25 MG/ML	M ; N ; O ; Y	N
Mekinist	trametinib dimethyl sulfoxide for soln	0.05 MG/ML	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	15-6.14 MG ; 20-8.19 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 & 50 & 100 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

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

			6	Capsules	21	DAYS
			120	Tablets	30	DAYS
	Selinexor Tab Therapy Pack 20 MG (100 MG Once Weekly)		20	Tablets	28	DAYS
	Selinexor Tab Therapy Pack 20 MG (40 MG Once Weekly)		8	Tablets	28	DAYS
	Selinexor Tab Therapy Pack 20 MG (40 MG Twice Weekly)		16	Tablets	28	DAYS
	Selinexor Tab Therapy Pack 20 MG (60 MG Once Weekly)		12	Tablets	28	DAYS
	Selinexor Tab Therapy Pack 20 MG (80 MG Once Weekly)		16	Tablets	28	DAYS
Afinitor ; Torpenz	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	30	Tablets	30	DAYS
Afinitor disperz	Everolimus Tab for Oral Susp 2 MG	2 MG	60	Tablets	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	Tablets	30	DAYS
Afinitor disperz	Everolimus Tab for Oral Susp 5 MG	5 MG	60	Tablets	30	DAYS
Akeega	niraparib tosylate-abiraterone acetate tab	50-500 MG	60	Tablets	30	DAYS
Akeega	niraparib tosylate-abiraterone acetate tab	100-500 MG	60	Tablets	30	DAYS
Alecensa	alectinib hcl cap	150 MG	240	Capsules	30	DAYS
Alunbrig	Brigatinib Tab	30 MG	120	Tablets	30	DAYS
Alunbrig	Brigatinib Tab	90 MG	30	Tablets	30	DAYS
Alunbrig	Brigatinib Tab	180 MG	30	Tablets	30	DAYS
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 & 180 MG	30	Tablets	180	DAYS
Augtyro	repotrectinib cap	40 MG	240	Capsules	30	DAYS
Ayvakit	avapritinib tab	100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG	30	Tablets	30	DAYS
Balversa	Erdafitinib Tab 3 MG	3 MG	90	Tablets	30	DAYS
Balversa	Erdafitinib Tab 4 MG	4 MG	60	Tablets	30	DAYS
Balversa	Erdafitinib Tab 5 MG	5 MG	30	Tablets	30	DAYS
Besremi	Ropeginterferon alfa-	500 MCG/ML	2	Syringes	28	DAYS
Bosulif	bosutinib cap	50 MG	30	Capsules	30	DAYS
Bosulif	bosutinib cap	100 MG	150	Capsules	30	DAYS
Bosulif	Bosutinib Tab	100 MG	90	Tablets	30	DAYS
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	30	Tablets	30	DAYS
Braftovi	encorafenib cap	75 MG	180	Capsules	30	DAYS
Brukinsa	Zanubrutinib Cap	80 MG	120	Capsules	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	20 MG	30	Tablets	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	40 MG	30	Tablets	30	DAYS
Cabometyx	Cabozantinib S-Malate Tab	60 MG	30	Tablets	30	DAYS
Calquence	acalabrutinib cap	100 MG	60	Capsules	30	DAYS
Calquence	acalabrutinib maleate tab	100 MG	60	Tablets	30	DAYS
Caprelsa	Vandetanib Tab	100 MG	60	Tablets	30	DAYS
Caprelsa	Vandetanib Tab	300 MG	30	Tablets	30	DAYS
Cometriq	Cabozantinib S-Mal Cap	80 & 20 MG	1	Carton	28	DAYS
Cometriq	Cabozantinib S-Mal Cap	3 x 20 MG & 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	Capsules	28	DAYS
Cotellic	cobimetinib fumarate tab	20 MG	63	Tablets	28	DAYS
Daurismo	Glasdegib Maleate Tab 100 MG (Base Equivalent)	100 MG	30	Tablets	30	DAYS
Daurismo	Glasdegib Maleate Tab 25 MG (Base Equivalent)	25 MG	60	Tablets	30	DAYS
Erivedge	Vismodegib Cap 150 MG	150 MG	30	Capsules	30	DAYS
Erleada	apalutamide tab	240 MG	30	Tablets	30	DAYS
Erleada	Apalutamide Tab 60 MG	60 MG	120	Tablets	30	DAYS
Fotivda	Tivozanib HCl Cap	0.89 MG	21	Capsules	28	DAYS
Fotivda	Tivozanib HCl Cap	1.34 MG	21	Capsules	28	DAYS
Fruzaqla	fruquintinib cap	1 MG	84	Capsules	28	DAYS
Fruzaqla	fruquintinib cap	5 MG	21	Capsules	28	DAYS
Gavreto	pralsetinib cap	100 MG	120	Capsules	30	DAYS
Gilotrif	afatinib dimaleate tab	20 MG ; 30 MG ; 40 MG	30	Tablets	30	DAYS
Gleevec	Imatinib Mesylate Tab	100 MG	90	Tablets	30	DAYS
Gleevec	Imatinib Mesylate Tab	400 MG	60		30	DAYS
Ibrance	palbociclib cap ; palbociclib tab	100 MG ; 125 MG ; 75 MG	21	Capsules	28	DAYS
Iclusig	Ponatinib HCl Tab	10 MG	30	Tablets	30	DAYS
Iclusig	Ponatinib HCl Tab	15 MG	30	Tablets	30	DAYS
Iclusig	Ponatinib HCl Tab	30 MG	30	Tablets	30	DAYS
Iclusig	Ponatinib HCl Tab	45 MG	30	Tablets	30	DAYS
Idhifa	Enasidenib Mesylate Tab 100 MG (Base Equivalent)	100 MG	30	Tablets	30	DAYS
Idhifa	Enasidenib Mesylate Tab 50 MG (Base Equivalent)	50 MG	30	Tablets	30	DAYS
Imbruvica	Ibrutinib Cap	70 MG	30	Capsules	30	DAYS
Imbruvica	Ibrutinib Cap	140 MG	90	Capsules	30	DAYS
Imbruvica	Ibrutinib Oral Susp	70 MG/ML	2	Bottles	30	DAYS
Imbruvica	ibrutinib tab	140 MG ; 280 MG ; 420 MG ; 560 MG	30	Tablets	30	DAYS
Inlyta	Axitinib Tab	1 MG	180	Tablets	30	DAYS
Inlyta	Axitinib Tab	5 MG	120	Tablets	30	DAYS
Inqovi	decitabine-cedazuridine tab	35-100 MG	5	Tablets	28	DAYS
Inrebic	Fedratinib HCl Cap 100 MG	100 MG	120	Capsules	30	DAYS
Iressa	gefitinib tab	250 MG	30	Tablets	30	DAYS
Iwilfin	eflornithine hcl tab	192 MG	240	Tablets	30	DAYS
Jakafi	ruxolitinib phosphate tab	10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG	60	Tablets	30	DAYS
Jaypirca	pirtobrutinib tab	50 MG	30	Tablets	30	DAYS
Jaypirca	pirtobrutinib tab	100 MG	60	Tablets	30	DAYS
Kisqali	Ribociclib Succinate Tab Pack 200 MG Daily Dose	200 MG	21	Tablets	28	DAYS
Kisqali	Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab)	200 MG	42	Tablets	28	DAYS
Kisqali	Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab)	200 MG	63	Tablets	28	DAYS
Kisqali femara 200 dose	Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 & 2.5 MG	49	Tablets	28	DAYS
Kisqali femara 400 dose	Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 & 2.5 MG	70	Tablets	28	DAYS
Kisqali femara 600 dose	Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 & 2.5 MG	91	Tablets	28	DAYS
Koselugo	Selumetinib Sulfate Cap 10 MG	10 MG	240	Capsules	30	DAYS
Koselugo	Selumetinib Sulfate Cap 25 MG	25 MG	120	Capsules	30	DAYS
Krazati	Adagrasib Tab	200 MG	180	Tablets	30	DAYS
Lenvima 10 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	30	Capsules	30	DAYS
Lenvima 12mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	90	Capsules	30	DAYS
Lenvima 14 mg daily dose	Lenvatinib Cap Therapy Pack	10 & 4 MG	60	Capsules	30	DAYS
Lenvima 18 mg daily dose	Lenvatinib Cap Ther Pack	10 MG & 2 x 4 MG	90	Capsules	30	DAYS
Lenvima 20 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	60	Capsules	30	DAYS
Lenvima 24 mg daily dose	Lenvatinib Cap Ther Pack	2 x 10 MG & 4 MG	90	Capsules	30	DAYS
Lenvima 4 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	30	Capsules	30	DAYS
Lenvima 8 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	60	Capsules	30	DAYS
Lonsurf	trifluridine-tipiracil tab	15-6.14 MG	60	Tablets	28	DAYS
Lonsurf	trifluridine-tipiracil tab	20-8.19 MG	80	Tablets	28	DAYS
Lorbrena	Lorlatinib Tab	25 MG	90	Tablets	30	DAYS
Lorbrena	Lorlatinib Tab	100 MG	30	Tablets	30	DAYS
Lumakras	sotorasib tab	320 MG	90	Tablets	30	DAYS
Lumakras	Sotorasib Tab	120 MG	240	Tablets	30	DAYS
Lynparza	olaparib tab	100 MG ; 150 MG	120	Tablets	30	DAYS
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	84	Tablets	28	DAYS
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	112	Tablets	28	DAYS
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	140	Tablets	28	DAYS
Mekinist	trametinib dimethyl sulfoxide for soln	0.05 MG/ML	1170	mLs	28	DAYS
Mekinist	Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)	0.5 MG	90	Tablets	30	DAYS
Mekinist	Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)	2 MG	30	Tablets	30	DAYS
Mektovi	binimetinib tab	15 MG	180	Tablets	30	DAYS
Nerlynx	Neratinib Maleate Tab	40 MG	180	Tablets	30	DAYS
Nexavar	Sorafenib Tosylate Tab 200 MG (Base Equivalent)	200 MG	120	Tablets	30	DAYS
Ninlaro	ixazomib citrate cap	2.3 MG ; 3 MG ; 4 MG	3	Capsules	28	DAYS
Nubeqa	Darolutamide Tab 300 MG	300 MG	120	Tablets	30	DAYS
Odomzo	sonidegib phosphate cap	200 MG	30	Capsules	30	DAYS
Ogsiveo	nirogacestat hydrobromide tab	50 MG	180	Tablets	30	DAYS
Ogsiveo	nirogacestat hydrobromide tab	100 MG	56	Tablets	28	DAYS
Ogsiveo	nirogacestat hydrobromide tab	150 MG	56	Tablets	28	DAYS
Ojemda	tovorafenib for oral susp	25 MG/ML	96	mLs	28	DAYS
Ojemda	tovorafenib tab	100 MG	24	Tablets	28	DAYS
Ojjaara	momelotinib dihydrochloride tab	100 MG	30	Tablets	30	DAYS
Ojjaara	momelotinib dihydrochloride tab	150 MG	30	Tablets	30	DAYS
Ojjaara	momelotinib dihydrochloride tab	200 MG	30	Tablets	30	DAYS
Onureg	azacitidine tab	200 MG ; 300 MG	14	Tablets	28	DAYS
Orgovyx	relugolix tab	120 MG	30	Tablets	30	DAYS
Orserdu	elacestrant hydrochloride tab	86 MG	90	Tablets	30	DAYS
Orserdu	elacestrant hydrochloride tab	345 MG	30	Tablets	30	DAYS
Pemazyre	Pemigatinib Tab 13.5 MG	13.5 MG	14	Tablets	21	DAYS
Pemazyre	Pemigatinib Tab 4.5 MG	4.5 MG	14	Tablets	21	DAYS
Pemazyre	Pemigatinib Tab 9 MG	9 MG	14	Tablets	21	DAYS
Piqray 200mg daily dose	Alpelisib Tab Therapy Pack 200 MG Daily Dose	200 MG	28	Tablets	28	DAYS
Piqray 250mg daily dose	Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs)	200 & 50 MG	56	Tablets	28	DAYS
Piqray 300mg daily dose	Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab)	150 MG	56	Tablets	28	DAYS
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	21	Capsules	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	Tablets	30	DAYS
Retevmo	Selpercatinib Cap	40 MG	180	Capsules	30	DAYS
Retevmo	Selpercatinib Cap	80 MG	120	Capsules	30	DAYS
Revlimid	Lenalidomide Cap 10 MG	10 MG	30	Capsules	30	DAYS
Revlimid	Lenalidomide Cap 15 MG	15 MG	21	Capsules	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 MG	21	Capsules	21	DAYS
Revlimid	Lenalidomide Cap 25 MG	25 MG	21	Capsules	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	Capsules	30	DAYS
Revlimid	Lenalidomide Caps 2.5 MG	2.5 MG	30	Capsules	30	DAYS
Rezlidhia	Olutasidenib Cap	150 MG	60	Capsules	30	DAYS
Rozlytrek	Entrectinib Cap 100 MG	100 MG	30	Capsules	30	DAYS
Rozlytrek	Entrectinib Cap 200 MG	200 MG	90	Capsules	30	DAYS
Rozlytrek	entrectinib pellet pack	50 MG	336	Packets	28	DAYS
Rubraca	Rucaparib Camsylate Tab 200 MG (Base Equivalent)	200 MG	120	Tablets	30	DAYS
Rubraca	Rucaparib Camsylate Tab 250 MG (Base Equivalent)	250 MG	120	Tablets	30	DAYS
Rubraca	Rucaparib Camsylate Tab 300 MG (Base Equivalent)	300 MG	120	Tablets	30	DAYS
Rydapt	Midostaurin Cap 25 MG	25 MG	240	Capsules	30	DAYS
Scemblix	Asciminib HCl Tab	20 MG	60	Tablets	30	DAYS
Scemblix	Asciminib HCl Tab	40 MG	300	Tablets	30	DAYS
Scemblix	asciminib hcl tab	100 MG	120	Tablets	30	DAYS
Sprycel	Dasatinib Tab	20 MG	90	Tablets	30	DAYS
Sprycel	Dasatinib Tab	50 MG	30	Tablets	30	DAYS
Sprycel	Dasatinib Tab	70 MG	30	Tablets	30	DAYS
Sprycel	Dasatinib Tab	80 MG	30	Tablets	30	DAYS
Sprycel	Dasatinib Tab	100 MG	30	Tablets	30	DAYS
Sprycel	Dasatinib Tab	140 MG	30	Tablets	30	DAYS
Stivarga	regorafenib tab	40 MG	84	Tablets	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	Capsules	30	DAYS
Sutent	Sunitinib Malate Cap 25 MG (Base Equivalent)	25 MG	30	Capsules	30	DAYS
Sutent	Sunitinib Malate Cap 37.5 MG (Base Equivalent)	37.5 MG	30	Capsules	30	DAYS
Sutent	Sunitinib Malate Cap 50 MG (Base Equivalent)	50 MG	30	Capsules	30	DAYS
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	120	Tablets	30	DAYS
Tafinlar	dabrafenib mesylate cap	50 MG ; 75 MG	120	Capsules	30	DAYS
Tafinlar	dabrafenib mesylate tab for oral susp	10 MG	840	Tablets	28	DAYS
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	30	Tablets	30	DAYS
Talzenna	talazoparib tosylate cap	0.1 MG	30	Capsules	30	DAYS
Talzenna	talazoparib tosylate cap	0.35 MG	30	Capsules	30	DAYS
Talzenna	Talazoparib Tosylate Cap	0.5 MG	30	Capsules	30	DAYS
Talzenna	Talazoparib Tosylate Cap	0.75 MG	30	Capsules	30	DAYS
Talzenna	Talazoparib Tosylate Cap 0.25 MG (Base Equivalent)	0.25 MG	90	Capsules	30	DAYS
Talzenna	Talazoparib Tosylate Cap 1 MG (Base Equivalent)	1 MG	30	Capsules	30	DAYS
Tarceva	Erlotinib HCl Tab	25 MG	60	Tablets	30	DAYS
Tarceva	Erlotinib HCl Tab	100 MG	30	Tablets	30	DAYS
Tarceva	Erlotinib HCl Tab	150 MG	30	Tablets	30	DAYS
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	120	Capsules	30	DAYS
Tazverik	tazemetostat hbr tab	200 MG	240	Tablets	30	DAYS
Thalomid	Thalidomide Cap 100 MG	100 MG	120	Tablets	30	DAYS
Thalomid	Thalidomide Cap 150 MG	150 MG	60	Capsules	30	DAYS
Thalomid	Thalidomide Cap 200 MG	200 MG	60	Capsules	30	DAYS
Thalomid	Thalidomide Cap 50 MG	50 MG	90	Capsules	30	DAYS
Tibsovo	Ivosidenib Tab 250 MG	250 MG	60	Tablets	30	DAYS
Truqap	capivasertib tab	160 MG	64	Tablets	28	DAYS
Truqap	capivasertib tab	200 MG	64	Tablets	28	DAYS
Truseltiq	Infigratinib Phos Cap Pack	100 & 25 MG	42	Capsules	28	DAYS
Truseltiq	Infigratinib Phos Cap Pack	100 & 25 MG	42	Capsules	28	DAYS
Truseltiq	Infigratinib Phos Cap Ther Pack	25 MG	42	Capsules	28	DAYS
Truseltiq	Infigratinib Phos Cap Ther Pack	25 MG	63	Capsules	28	DAYS
Truseltiq	Infigratinib Phos Cap Ther Pack	100 MG	21	Capsules	28	DAYS
Tukysa	Tucatinib Tab	50 MG	300	Tablets	30	DAYS
Tukysa	Tucatinib Tab	150 MG	120	Tablets	30	DAYS
Turalio	Pexidartinib HCl Cap	125 MG	120	Capsules	30	DAYS
Turalio	Pexidartinib HCl Cap	200 MG	120	Capsules	30	DAYS
Tykerb	Lapatinib Ditosylate Tab	250 MG	180	Tablets	30	DAYS
Vanflyta	quizartinib dihydrochloride tab	17.7 MG	28	Tablets	28	DAYS
Vanflyta	quizartinib dihydrochloride tab	26.5 MG	56	Tablets	28	DAYS
Venclexta	Venetoclax Tab 10 MG	10 MG	60	Tablets	30	DAYS
Venclexta	Venetoclax Tab 100 MG	100 MG	180	Tablets	30	DAYS
Venclexta	Venetoclax Tab 50 MG	50 MG	30	Tablets	30	DAYS
Venclexta starting pack	Venetoclax Tab Therapy Starter Pack 10 & 50 & 100 MG	10 & 50 & 100 MG	1	Pack	180	DAYS
Verzenio	abemaciclib tab	100 MG ; 150 MG ; 200 MG ; 50 MG	60	Tablets	30	DAYS
Vitrakvi	Larotrectinib Sulfate Cap 100 MG (Base Equivalent)	100 MG	60	Capsules	30	DAYS
Vitrakvi	Larotrectinib Sulfate Cap 25 MG (Base Equivalent)	25 MG	180	Capsules	30	DAYS
Vitrakvi	Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent)	20 MG/ML	300	mLs	30	DAYS
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	30	Tablets	30	DAYS
Vonjo	Pacritinib Citrate Cap	100 MG	120	Capsules	30	DAYS
Votrient	Pazopanib HCl Tab	200 MG	120	Tablets	30	DAYS
Welireg	Belzutifan Tab	40 MG	90	Tablets	30	DAYS
Xalkori	crizotinib cap	200 MG ; 250 MG	120	Capsules	30	DAYS
Xalkori	crizotinib cap sprinkle	20 MG	120	Capsules	30	DAYS
Xalkori	crizotinib cap sprinkle	50 MG	120	Capsules	30	DAYS
Xalkori	crizotinib cap sprinkle	150 MG	180	Capsules	30	DAYS
Xospata	Gilteritinib Fumarate Tablet	40 MG	90	Tablets	30	DAYS
Xpovio	Selinexor Tab Therapy Pack	40 MG	4	Tablets	28	DAYS
Xpovio	Selinexor Tab Therapy Pack	40 MG	8	Tablets	28	DAYS
Xpovio	Selinexor Tab Therapy Pack	40 MG	8	Tablets	28	DAYS
Xpovio	Selinexor Tab Therapy Pack	50 MG	8	Tablets	28	DAYS
Xpovio	Selinexor Tab Therapy Pack	60 MG	4	Tablets	28	DAYS
Xpovio 60 mg twice weekly	Selinexor Tab Therapy Pack 20 MG (60 MG Twice Weekly)	20 MG	24	Tablets	28	DAYS
Xpovio 80 mg twice weekly	Selinexor Tab Therapy Pack 20 MG (80 MG Twice Weekly)	20 MG	32	Tablets	28	DAYS
Xtandi	enzalutamide cap	40 MG	120	Capsules	30	DAYS
Xtandi	Enzalutamide Tab	40 MG	120	Tablets	30	DAYS
Xtandi	Enzalutamide Tab	80 MG	60	Tablets	30	DAYS
Yonsa	abiraterone acetate tab 125 mg	125 MG	120	Tablets	30	DAYS
Zejula	niraparib tosylate cap	100 MG	90	Capsules	30	DAYS
Zejula	niraparib tosylate tab	100 MG	30	Tablets	30	DAYS
Zejula	niraparib tosylate tab	200 MG	30	Tablets	30	DAYS
Zejula	niraparib tosylate tab	300 MG	30	Tablets	30	DAYS
Zelboraf	Vemurafenib Tab 240 MG	240 MG	240	Tablets	30	DAYS
Zolinza	Vorinostat Cap 100 MG	100 MG	120	Capsules	30	DAYS
Zydelig	idelalisib tab	100 MG ; 150 MG	60	Tablets	30	DAYS
Zykadia	ceritinib tab	150 MG	90	Tablets	30	DAYS
Zytiga	Abiraterone Acetate Tab 250 MG	250 ; 250 MG	120	Tablets	30	DAYS
Zytiga	Abiraterone Acetate Tab 500 MG	500 MG	60	Tablets	30	DAYS

ADDITIONAL QUANTITY LIMIT INFORMATION

Wildcard	Target Brand Agent Name(s)	Target Generic Agent Name(s)	Strength	Additional QL Information	Targeted NDCs When Exclusions Exist	Effective Date	Term Date

21532530007310	Afinitor disperz	Everolimus Tab for Oral Susp 2 MG	2 MG	Calculation is based on 4.5 mg/m2 with a standard BSA of 2.0 and rounding up to nearest full dose
214500800001	Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	The quantity limits for Pomalyst are based on dosing for multiple myeloma, which is given daily for 21 days of a 28 day cycle
99394050000140	Revlimid	Lenalidomide Cap 15 MG	15 MG	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
99394050000150	Revlimid	Lenalidomide Cap 25 MG	25 MG	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
2153305000	Stivarga	regorafenib tab	40 MG	based 160 mg daily for 21 days of a 28 day cycle

CLIENT SUMMARY – PRIOR AUTHORIZATION

Target Brand Agent Name(s)	Target Generic Agent Name(s)	Strength	Client Formulary
			Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
			Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	tretinoin cap	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor ; Torpenz	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor ; Torpenz	Everolimus Tab 10 MG	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor ; Torpenz	Everolimus Tab 5 MG	5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor disperz	everolimus tab for oral susp	2 MG ; 3 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Akeega	niraparib tosylate-abiraterone acetate tab	100-500 MG ; 50-500 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
Alecensa	alectinib hcl cap	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	brigatinib tab	180 MG ; 30 MG ; 90 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	brigatinib tab ; brigatinib tab initiation therapy pack	180 MG ; 30 MG ; 90 & 180 MG ; 90 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 & 180 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Augtyro	repotrectinib cap	40 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
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 ; 4 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 cap ; bosutinib tab	100 MG ; 400 MG ; 50 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
Brukinsa	zanubrutinib cap	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cabometyx	cabozantinib s-malate tab	20 MG ; 40 MG ; 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 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	100 MG ; 300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Caprelsa	vandetanib tab	100 MG ; 300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cometriq	cabozantinib s-mal cap ; cabozantinib s-malate cap	20 MG ; 3 x 20 MG & 80 MG ; 80 & 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 ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Erivedge	vismodegib cap	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Erleada	apalutamide tab	240 MG ; 60 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Fotivda	tivozanib hcl cap	0.89 MG ; 1.34 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Fruzaqla	fruquintinib cap	1 MG ; 5 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
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
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 ; 400 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Hycamtin	topotecan hcl cap	0.25 MG ; 1 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ibrance	palbociclib cap	100 MG ; 125 MG ; 75 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 ; 15 MG ; 30 MG ; 45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Idhifa	enasidenib mesylate tab	100 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Imbruvica	ibrutinib cap ; ibrutinib oral susp ; ibrutinib tab	140 MG ; 280 MG ; 420 MG ; 560 MG ; 70 MG ; 70 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inlyta	axitinib tab	1 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inlyta	axitinib tab	1 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inqovi	decitabine-cedazuridine tab	35-100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inqovi	decitabine-cedazuridine tab	35-100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inrebic	fedratinib hcl cap	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
Iressa	gefitinib tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iwilfin	eflornithine hcl tab	192 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 ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali	ribociclib succinate tab pack	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali femara 200 dose ; Kisqali femara 400 dose ; Kisqali femara 600 dose	ribociclib	200 & 2.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Koselugo	selumetinib sulfate cap	10 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 ; 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 & 4 MG ; 10 MG ; 10 MG & 2 x 4 MG ; 2 x 10 MG & 4 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lonsurf	trifluridine-tipiracil tab	15-6.14 MG ; 20-8.19 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lorbrena	lorlatinib tab	100 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lorbrena	lorlatinib tab	100 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lumakras	sotorasib tab	120 MG ; 320 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
Lysodren	mitotane tab	500 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
Matulane	procarbazine hcl cap	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Mekinist	trametinib dimethyl sulfoxide for soln	0.05 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
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
Ogsiveo	nirogacestat hydrobromide tab	100 MG ; 150 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojemda	tovorafenib for oral susp ; tovorafenib tab	100 MG ; 25 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojjaara	momelotinib dihydrochloride tab	100 MG ; 150 MG ; 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 & 50 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 MG ; 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
Rozlytrek	entrectinib pellet pack	50 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
Scemblix	asciminib hcl tab	100 MG ; 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
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
Tafinlar	dabrafenib mesylate tab for oral susp	10 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	0.1 MG ; 0.25 MG ; 0.35 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
Truqap	capivasertib tab	160 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	infigratinib phos cap pack ; infigratinib phos cap ther pack	100 & 25 MG ; 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
Vanflyta	quizartinib dihydrochloride tab	17.7 MG ; 26.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
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 & 50 & 100 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 ; crizotinib cap sprinkle	150 MG ; 20 MG ; 200 MG ; 250 MG ; 50 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 60 mg twice 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 micronized 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
Zejula	niraparib tosylate tab	100 MG ; 200 MG ; 300 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 ; 250 MG ; 500 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
			Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
			Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	Selinexor Tab Therapy Pack 20 MG (100 MG Once Weekly)		Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	Selinexor Tab Therapy Pack 20 MG (40 MG Once Weekly)		Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	Selinexor Tab Therapy Pack 20 MG (40 MG Twice Weekly)		Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	Selinexor Tab Therapy Pack 20 MG (60 MG Once Weekly)		Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
	Selinexor Tab Therapy Pack 20 MG (80 MG Once Weekly)		Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor ; Torpenz	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
Akeega	niraparib tosylate-abiraterone acetate tab	50-500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Akeega	niraparib tosylate-abiraterone acetate tab	100-500 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	30 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 Initiation Therapy Pack	90 & 180 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Augtyro	repotrectinib cap	40 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 cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Bosulif	bosutinib cap	50 MG	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	40 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	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	80 & 20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cometriq	Cabozantinib S-Mal Cap	3 x 20 MG & 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
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
Fruzaqla	fruquintinib cap	1 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Fruzaqla	fruquintinib cap	5 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	400 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
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	15 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
Iclusig	Ponatinib HCl Tab	45 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
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	5 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
Inqovi	decitabine-cedazuridine tab	35-100 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
Iwilfin	eflornithine hcl tab	192 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 & 2.5 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 & 2.5 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 & 2.5 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 & 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 18 mg daily dose	Lenvatinib Cap Ther Pack	10 MG & 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 x 10 MG & 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	20-8.19 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lonsurf	trifluridine-tipiracil tab	15-6.14 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
Lorbrena	Lorlatinib Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lumakras	sotorasib tab	320 MG	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 for soln	0.05 MG/ML	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
Ogsiveo	nirogacestat hydrobromide tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ogsiveo	nirogacestat hydrobromide tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ogsiveo	nirogacestat hydrobromide tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojemda	tovorafenib for oral susp	25 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojemda	tovorafenib tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojjaara	momelotinib dihydrochloride tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojjaara	momelotinib dihydrochloride tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ojjaara	momelotinib dihydrochloride tab	150 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 & 50 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	40 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
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 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 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
Rozlytrek	entrectinib pellet pack	50 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	100 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
Scemblix	Asciminib HCl Tab	20 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	80 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
Sprycel	Dasatinib Tab	140 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	70 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
Tafinlar	dabrafenib mesylate tab for oral susp	10 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	0.35 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	talazoparib tosylate cap	0.1 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
Truqap	capivasertib tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truqap	capivasertib tab	160 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Pack	100 & 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Pack	100 & 25 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	200 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
Tykerb	Lapatinib Ditosylate Tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vanflyta	quizartinib dihydrochloride tab	17.7 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vanflyta	quizartinib dihydrochloride tab	26.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
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 & 50 & 100 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
Xalkori	crizotinib cap sprinkle	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xalkori	crizotinib cap sprinkle	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xalkori	crizotinib cap sprinkle	150 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	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	Selinexor Tab Therapy Pack	60 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 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	80 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
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
Zejula	niraparib tosylate tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zejula	niraparib tosylate tab	300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zejula	niraparib tosylate tab	200 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 ; 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

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

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

*- preferred agent may be targeted in another utilization management program and require Prior Authorization

Initial Evaluation

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

ONE of the following:
1. The patient has been 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 labeled indication for the requested agent OR
    2. The patient has a compendia supported indication [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. If the patient has an FDA labeled indication, then ONE of the following:
    1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
    2. There is support for using the requested agent for the patient’s age for the requested indication AND
  3. ONE of the following:
    1. The requested indication does NOT require specific genetic/diagnostic testing per FDA labeling or supported by compendia for the requested agent OR
    2. The requested indication requires genetic/specific diagnostic testing per FDA labeling or compendia for the requested agent AND BOTH of the following:
      1. Genetic/specific diagnostic testing has been completed AND
      2. The results of the genetic/specific diagnostic testing indicate therapy with the requested agent is appropriate 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 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 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 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 for the requested indication OR
    3. The patient has an intolerance or hypersensitivity to the appropriate number and type(s) of prerequisite agent(s) listed in the FDA labeling or compendia for the requested indication OR
    4. The patient has an FDA labeled contraindication to ALL of the required prerequisite agent(s) listed in the FDA labeling or compendia 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

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 ONE preferred agent for the requested indication OR
  2. The patient has an intolerance or hypersensitivity to ONE preferred agent 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. There is support for the 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
3. 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
4. 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
5. If the request is for Mekinist oral solution, ONE of the following:
  1. The patient weighs less than 26 kg OR
  2. The patient has tried and had an inadequate response to Mekinist oral tablets OR
  3. The patient has an intolerance or hypersensitivity to Mekinist oral tablets that is not expected to occur with the requested agent OR
  4. The patient has an FDA labeled contraindication to Mekinist oral tablets that is not expected to occur with the requested agent OR
  5. There is support for the use of the requested agent over Mekinist oral tablets (e.g., swallowing difficulties) AND
6. If the requested agent is Bosulif capsules, then ONE of the following:
  1. The requested dose is less than 500 mg OR
  2. There is support for the use of the capsules over the Bosulif tablets (e.g., swallowing difficulties) AND
ONE of the following:

Brand	Generic Equivalent
Afinitor	everolimus
Afinitor Disperz	everolimus
Gleevec	imatinib
Nexavar	sorafenib
Sutent	sunitinib
Tarceva	erlotinib
Targretin	bexarotene
Temodar	temozolomide
Tykerb	lapatinib
Xeloda	capecitabine
Zytiga	abiraterone

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

Compendia Allowed: NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A

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.

*Step therapy requirement may not apply if a prior health plan paid for the medication - documentation of a paid claim may be required.

Renewal Evaluation

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

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process (Note: patients not previously approved for the requested agent will require initial evaluation review) AND
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
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
If the request is for Mekinist oral solution, ONE of the following:
1. The patient weighs less than 26 kg OR
2. The patient has tried and had an inadequate response to Mekinist oral tablets OR
3. The patient has an intolerance or hypersensitivity to Mekinist oral tablets that is not expected to occur with the requested agent OR
4. The patient has an FDA labeled contraindication to Mekinist oral tablets that is not expected to occur with the requested agent OR
5. There is support for the use of the requested agent over Mekinist oral tablets (e.g., swallowing difficulties) AND
If the requested agent is Bosulif capsules, then ONE of the following:
1. The requested dose is less than 500 mg OR
2. There is support for the use of the capsules over the Bosulif tablets (e.g., swallowing difficulties) AND
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
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
Nexavar	sorafenib
Sutent	sunitinib
Tarceva	erlotinib
Targretin	bexarotene
Temodar	temozolomide
Tykerb	lapatinib
Xeloda	capecitabine
Zytiga	abiraterone

The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the requested brand agent OR
The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the requested brand agent OR
There is support for the use of the requested brand agent over the generic equivalent AND
The patient does not have any FDA labeled contraindications to the requested agent AND
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: The requested quantity (dose) does NOT exceed the program quantity limit OR ALL of the following: The requested quantity (dose) exceeds the program quantity limit AND The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit OR ALL of the following: The requested quantity (dose) exceeds the program quantity limit AND The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND There is support for 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

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:

The requested quantity (dose) does NOT exceed the program quantity limit OR
ALL of the following:
1. The requested quantity (dose) exceeds 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
ALL of the following:
1. The requested quantity (dose) exceeds the program quantity limit AND
2. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
3. There is support for 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.

ALBP _ Commercial _ CSReg _ Self-Administered_Oncology_Agents_PAQL _ProgSum_ 10-01-2024 _

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