Asset Publisher

ph-10691

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

Policy Number: PH-10691

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

CLIENT SUMMARY – PRIOR AUTHORIZATION Continued

Mekinist	trametinib dimethyl sulfoxide tab	0.5 MG ; 2 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Mektovi	binimetinib tab	15 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nerlynx	neratinib maleate tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nerlynx	neratinib maleate tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nexavar	sorafenib tosylate tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ninlaro	ixazomib citrate cap	2.3 MG ; 3 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nubeqa	darolutamide tab	300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Odomzo	sonidegib phosphate cap	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Onureg	azacitidine tab	200 MG ; 300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Orgovyx	relugolix tab	120 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Orserdu	elacestrant hydrochloride tab	345 MG ; 86 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pemazyre	pemigatinib tab	13.5 MG ; 4.5 MG ; 9 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Piqray 200mg daily dose ; Piqray 250mg daily dose ; Piqray 300mg daily dose	alpelisib tab pack ; alpelisib tab therapy pack	150 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Qinlock	ripretinib tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Qinlock	ripretinib tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Retevmo	selpercatinib cap	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Retevmo	selpercatinib cap	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	lenalidomide cap ; lenalidomide caps	10 MG ; 15 MG ; 2.5 ; 2.5 MG ; 20 ; 20 MG ; 25 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rezlidhia	olutasidenib cap	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rozlytrek	entrectinib cap	100 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rubraca	rucaparib camsylate tab	200 MG ; 250 MG ; 300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rydapt	midostaurin cap	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	dasatinib tab	100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Stivarga	regorafenib tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sutent	sunitinib malate cap	12.5 MG ; 25 MG ; 37.5 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tafinlar	dabrafenib mesylate cap	50 MG ; 75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	talazoparib tosylate cap	0.25 MG ; 0.5 MG ; 0.75 MG ; 1 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tarceva	erlotinib hcl tab	100 MG ; 150 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tarceva	erlotinib hcl tab	100 MG ; 150 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Targretin	bexarotene cap	75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Targretin	Bexarotene Gel 1%	1 %	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tazverik	tazemetostat hbr tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Temodar	temozolomide cap	100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Thalomid	thalidomide cap	100 MG ; 150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tibsovo	ivosidenib tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	infigratinib phos cap pack ; infigratinib phos cap ther pack	100 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tukysa	tucatinib tab	150 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tukysa	tucatinib tab	150 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Turalio	pexidartinib hcl cap	125 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Turalio	pexidartinib hcl cap	125 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tykerb	lapatinib ditosylate tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tykerb	lapatinib ditosylate tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ukoniq	umbralisib tosylate tab	200 MG
Venclexta	venetoclax tab	10 MG ; 100 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Venclexta starting pack	venetoclax tab therapy starter pack	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Verzenio	abemaciclib tab	100 MG ; 150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vitrakvi	larotrectinib sulfate cap	100 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vitrakvi	larotrectinib sulfate oral soln	20 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vonjo	pacritinib citrate cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Votrient	pazopanib hcl tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Votrient	pazopanib hcl tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Welireg	belzutifan tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xalkori	crizotinib cap	200 MG ; 250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xalkori	crizotinib cap	200 MG ; 250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xeloda	capecitabine tab	150 MG ; 500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xospata	gilteritinib fumarate tablet	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xospata	gilteritinib fumarate tablet	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio ; Xpovio 100 mg once weekly ; Xpovio 40 mg once weekly ; Xpovio 40 mg twice weekly ; Xpovio 60 mg once weekly ; Xpovio 60 mg twice weekly ; Xpovio 80 mg once weekly ; Xpovio 80 mg twice weekly	selinexor tab therapy pack	20 MG ; 40 MG ; 50 MG ; 60 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xtandi	enzalutamide cap	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xtandi	enzalutamide tab	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Yonsa	abiraterone acetate tab	125 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zejula	niraparib tosylate cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zelboraf	vemurafenib tab	240 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zolinza	vorinostat cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zydelig	idelalisib tab	100 MG ; 150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zykadia	ceritinib tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zykadia	ceritinib tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zytiga	abiraterone acetate tab	250 MG ; 500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Besremi	ropeginterferon alfa-	500 MCG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Gleevec	imatinib mesylate tab	100 MG ; 400 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iclusig	ponatinib hcl tab	10 MG ; 15 MG ; 30 MG ; 45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Scemblix	asciminib hcl tab	20 MG ; 40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	dasatinib tab	100 MG ; 140 MG ; 20 MG ; 50 MG ; 70 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)	Target Generic Agent Name(s)	Strength	Client Formulary
Afinitor	everolimus tab	10 MG ; 2.5 MG ; 5 MG ; 7.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor disperz	Everolimus Tab for Oral Susp 2 MG	2 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor disperz	Everolimus Tab for Oral Susp 3 MG	3 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Afinitor disperz	Everolimus Tab for Oral Susp 5 MG	5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alecensa	alectinib hcl cap	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	Brigatinib Tab	180 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	Brigatinib Tab	90 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	Brigatinib Tab	30 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Alunbrig	Brigatinib Tab Initiation Therapy Pack	90 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ayvakit	avapritinib tab	100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Balversa	Erdafitinib Tab 3 MG	3 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Balversa	Erdafitinib Tab 4 MG	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Balversa	Erdafitinib Tab 5 MG	5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Besremi	Ropeginterferon alfa-	500 MCG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Bosulif	Bosutinib Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Bosulif	bosutinib tab	100 MG ; 400 MG ; 500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Braftovi	encorafenib cap	75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Brukinsa	Zanubrutinib Cap	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cabometyx	Cabozantinib S-Malate Tab	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cabometyx	Cabozantinib S-Malate Tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cabometyx	Cabozantinib S-Malate Tab	60 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Calquence	acalabrutinib cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Calquence	acalabrutinib maleate tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Caprelsa	Vandetanib Tab	300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Caprelsa	Vandetanib Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cometriq	Cabozantinib S-Mal Cap	3 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cometriq	Cabozantinib S-Mal Cap	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cometriq	Cabozantinib S-Malate Cap	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Copiktra	duvelisib cap	15 MG ; 25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Cotellic	cobimetinib fumarate tab	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Daurismo	Glasdegib Maleate Tab 100 MG (Base Equivalent)	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Daurismo	Glasdegib Maleate Tab 25 MG (Base Equivalent)	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Erivedge	Vismodegib Cap 150 MG	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Erleada	apalutamide tab	240 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Erleada	Apalutamide Tab 60 MG	60 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Exkivity	Mobocertinib Succinate Cap	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Farydak	panobinostat lactate cap	10 MG ; 15 MG ; 20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Fotivda	Tivozanib HCl Cap	0.89 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Fotivda	Tivozanib HCl Cap	1.34 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Gavreto	pralsetinib cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Gilotrif	afatinib dimaleate tab	20 MG ; 30 MG ; 40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Gleevec	Imatinib Mesylate Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Gleevec	Imatinib Mesylate Tab	400 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ibrance	palbociclib cap ; palbociclib tab	100 MG ; 125 MG ; 75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iclusig	Ponatinib HCl Tab	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iclusig	Ponatinib HCl Tab	15 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iclusig	Ponatinib HCl Tab	45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iclusig	Ponatinib HCl Tab	30 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Idhifa	Enasidenib Mesylate Tab 100 MG (Base Equivalent)	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Idhifa	Enasidenib Mesylate Tab 50 MG (Base Equivalent)	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Imbruvica	Ibrutinib Cap	70 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Imbruvica	Ibrutinib Cap	140 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Imbruvica	Ibrutinib Oral Susp	70 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Imbruvica	ibrutinib tab	140 MG ; 280 MG ; 420 MG ; 560 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inlyta	Axitinib Tab	1 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inlyta	Axitinib Tab	5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inqovi	Decitabine-Cedazuridine Tab ; decitabine-cedazuridine tab	0 ; 35 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Inrebic	Fedratinib HCl Cap 100 MG	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Iressa	gefitinib tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Jakafi	ruxolitinib phosphate tab	10 MG ; 15 MG ; 20 MG ; 25 MG ; 5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Jaypirca	pirtobrutinib tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Jaypirca	pirtobrutinib tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali	Ribociclib Succinate Tab Pack 200 MG Daily Dose	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali	Ribociclib Succinate Tab Pack 400 MG Daily Dose (200 MG Tab)	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali	Ribociclib Succinate Tab Pack 600 MG Daily Dose (200 MG Tab)	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali femara 200 dose	Ribociclib 200 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali femara 400 dose	Ribociclib 400 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Kisqali femara 600 dose	Ribociclib 600 MG Dose (200 MG Tab) & Letrozole 2.5 MG TBPK	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Koselugo	Selumetinib Sulfate Cap 10 MG	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Koselugo	Selumetinib Sulfate Cap 25 MG	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Krazati	Adagrasib Tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 10 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 12mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 14 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 18 mg daily dose	Lenvatinib Cap Ther Pack	10 2 x 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 20 mg daily dose	Lenvatinib Cap Therapy Pack	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 24 mg daily dose	Lenvatinib Cap Ther Pack	2 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 4 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lenvima 8 mg daily dose	Lenvatinib Cap Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lonsurf	Trifluridine-Tipiracil Tab 15-6.14 MG	15 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lonsurf	Trifluridine-Tipiracil Tab 20-8.19 MG	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lorbrena	Lorlatinib Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lorbrena	Lorlatinib Tab	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lumakras	sotorasib tab	320	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lumakras	Sotorasib Tab	120 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lynparza	olaparib tab	100 MG ; 150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Lytgobi	Futibatinib Tab Therapy Pack	4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Mekinist	Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)	0.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Mekinist	Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)	2 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Mektovi	binimetinib tab	15 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nerlynx	Neratinib Maleate Tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nexavar	Sorafenib Tosylate Tab 200 MG (Base Equivalent)	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ninlaro	ixazomib citrate cap	2.3 MG ; 3 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Nubeqa	Darolutamide Tab 300 MG	300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Odomzo	sonidegib phosphate cap	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Onureg	azacitidine tab	200 MG ; 300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Orgovyx	relugolix tab	120 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Orserdu	elacestrant hydrochloride tab	345 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Orserdu	elacestrant hydrochloride tab	86 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pemazyre	Pemigatinib Tab 13.5 MG	13.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pemazyre	Pemigatinib Tab 4.5 MG	4.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pemazyre	Pemigatinib Tab 9 MG	9 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Piqray 200mg daily dose	Alpelisib Tab Therapy Pack 200 MG Daily Dose	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Piqray 250mg daily dose	Alpelisib Tab Pack 250 MG Daily Dose (200 MG & 50 MG Tabs)	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Piqray 300mg daily dose	Alpelisib Tab Pack 300 MG Daily Dose (2x150 MG Tab)	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Pomalyst	pomalidomide cap	1 MG ; 2 MG ; 3 MG ; 4 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Qinlock	Ripretinib Tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Retevmo	Selpercatinib Cap	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Retevmo	Selpercatinib Cap	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Cap 10 MG	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Cap 15 MG	15 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Cap 20 MG	20 ; 20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Cap 25 MG	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Cap 5 MG	5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Revlimid	Lenalidomide Caps 2.5 MG	2.5 ; 2.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rezlidhia	Olutasidenib Cap	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rozlytrek	Entrectinib Cap 100 MG	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rozlytrek	Entrectinib Cap 200 MG	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rubraca	Rucaparib Camsylate Tab 200 MG (Base Equivalent)	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rubraca	Rucaparib Camsylate Tab 250 MG (Base Equivalent)	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rubraca	Rucaparib Camsylate Tab 300 MG (Base Equivalent)	300 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Rydapt	Midostaurin Cap 25 MG	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Scemblix	Asciminib HCl Tab	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Scemblix	Asciminib HCl Tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	140 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	70 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sprycel	Dasatinib Tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Stivarga	regorafenib tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sutent	Sunitinib Malate Cap 12.5 MG (Base Equivalent)	12.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sutent	Sunitinib Malate Cap 25 MG (Base Equivalent)	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sutent	Sunitinib Malate Cap 37.5 MG (Base Equivalent)	37.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Sutent	Sunitinib Malate Cap 50 MG (Base Equivalent)	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tabrecta	capmatinib hcl tab	150 MG ; 200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tafinlar	dabrafenib mesylate cap	50 MG ; 75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tagrisso	osimertinib mesylate tab	40 MG ; 80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	Talazoparib Tosylate Cap	0.75 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	Talazoparib Tosylate Cap	0.5 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	Talazoparib Tosylate Cap 0.25 MG (Base Equivalent)	0.25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Talzenna	Talazoparib Tosylate Cap 1 MG (Base Equivalent)	1 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tarceva	Erlotinib HCl Tab	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tarceva	Erlotinib HCl Tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tarceva	Erlotinib HCl Tab	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tasigna	nilotinib hcl cap	150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tazverik	tazemetostat hbr tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Thalomid	Thalidomide Cap 100 MG	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Thalomid	Thalidomide Cap 150 MG	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Thalomid	Thalidomide Cap 200 MG	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Thalomid	Thalidomide Cap 50 MG	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tibsovo	Ivosidenib Tab 250 MG	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Pack	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Pack	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Ther Pack	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Ther Pack	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Truseltiq	Infigratinib Phos Cap Ther Pack	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tukysa	Tucatinib Tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tukysa	Tucatinib Tab	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Turalio	Pexidartinib HCl Cap	125 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Turalio	Pexidartinib HCl Cap	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Tykerb	Lapatinib Ditosylate Tab	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Ukoniq	umbralisib tosylate tab	200 MG
Venclexta	Venetoclax Tab 10 MG	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Venclexta	Venetoclax Tab 100 MG	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Venclexta	Venetoclax Tab 50 MG	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Venclexta starting pack	Venetoclax Tab Therapy Starter Pack 10 & 50 & 100 MG	10 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Verzenio	abemaciclib tab	100 MG ; 150 MG ; 200 MG ; 50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vitrakvi	Larotrectinib Sulfate Cap 100 MG (Base Equivalent)	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vitrakvi	Larotrectinib Sulfate Cap 25 MG (Base Equivalent)	25 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vitrakvi	Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent)	20 MG/ML	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vizimpro	dacomitinib tab	15 MG ; 30 MG ; 45 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Vonjo	Pacritinib Citrate Cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Votrient	Pazopanib HCl Tab	200 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Welireg	Belzutifan Tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xalkori	crizotinib cap	200 MG ; 250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xospata	Gilteritinib Fumarate Tablet	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio	Selinexor Tab Therapy Pack	50 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio	Selinexor Tab Therapy Pack	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio	Selinexor Tab Therapy Pack	60 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio	Selinexor Tab Therapy Pack	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio	Selinexor Tab Therapy Pack	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 100 mg once weekly	Selinexor Tab Therapy Pack 20 MG (100 MG Once Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 40 mg once weekly	Selinexor Tab Therapy Pack 20 MG (40 MG Once Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 40 mg twice weekly	Selinexor Tab Therapy Pack 20 MG (40 MG Twice Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 60 mg once weekly	Selinexor Tab Therapy Pack 20 MG (60 MG Once Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 60 mg twice weekly	Selinexor Tab Therapy Pack 20 MG (60 MG Twice Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 80 mg once weekly	Selinexor Tab Therapy Pack 20 MG (80 MG Once Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xpovio 80 mg twice weekly	Selinexor Tab Therapy Pack 20 MG (80 MG Twice Weekly)	20 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xtandi	enzalutamide cap	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xtandi	Enzalutamide Tab	40 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Xtandi	Enzalutamide Tab	80 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Yonsa	abiraterone acetate tab 125 mg	125 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zejula	niraparib tosylate cap	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zelboraf	Vemurafenib Tab 240 MG	240 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zolinza	Vorinostat Cap 100 MG	100 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zydelig	idelalisib tab	100 MG ; 150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zykadia	ceritinib tab	150 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zytiga	Abiraterone Acetate Tab 250 MG	250 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx
Zytiga	Abiraterone Acetate Tab 500 MG	500 MG	Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

PREFERRED AGENTS

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Preferred agent options are as follows.

Indication(s)	Number of Preferred Required	Preferred Agent(s)	Non-Preferred Agent(s)
Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia in chronic phase	1 preferred agent	Imatinib (generic), Sprycel	Bosulif, Tasigna
Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase with the T315I mutation	1 preferred agent	Iclusig	Scemblix
Polycythemia Vera	1 preferred agent	Peginterferon*	BESREMi

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

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

Initial Evaluation

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

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

Indication(s)	Number of Preferred Required	Preferred Agent(s)	Non-Preferred Agent(s)
Newly diagnosed adult and pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia in chronic phase	1 preferred agent	Imatinib (generic), Sprycel	Bosulif, Tasigna
Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase with the T315I mutation	1 preferred agent	Iclusig	Scemblix
Polycythemia Vera	1 preferred agent	Peginterferon	BESREMi

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

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

1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the requested brand agent OR
2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the requested brand agent OR
3. The prescriber has provided information to support the use of the requested brand agent over the generic equivalent AND
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 3 months for dose titration requests over the program quantity limit and Vitrakvi; Up to 12 months for all other requests, approve starter packs and loading doses where appropriate and maintenance dose for the remainder of the authorization

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

Renewal Evaluation

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

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process 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
3. If the requested agent is for one of the following brand agents with a generic equivalent (listed below), then ONE of the following:

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

1. 1. The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the requested brand agent OR
  2. The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the requested brand agent OR
  3. The prescriber has provided information to support the use of the requested brand agent over the generic equivalent AND
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) is greater than 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) is greater than the program quantity limit AND The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND The prescriber has provided information in support of therapy with a higher dose for the requested indication Length of Approval: Up to 3 months for dose titration requests over the program quantity limit and Vitrakvi; Up to 12 months for all other requests, approve starter packs/loading doses where appropriate and maintenance doses for the remainder of the authorization

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

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

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

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

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

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