Asset Publisher
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. |
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Safety (3-121) |
|
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 |