Asset Publisher
Self-Administered Oncology Agents Prior Authorization with Quantity Limit Program Summary
Policy Number: PH-91069
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx, SourceRx-Performance, and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
|
Effective Date |
Date of Origin |
|
01-01-2026 |
05-01-2001 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
|
Safety |
|
REFERENCES
|
Number |
Reference |
|
1 |
Voranigo prescribing information. Servier Pharmaceutical LLC. April 2025. |
|
2 |
Lazcluze prescribing information. Janssen Biotech, Inc. August 2024. |
|
3 |
Afinitor/Afinitor Disperz prescribing information. Novartis Pharmaceuticals Corporation. February 2022. |
|
4 |
Alecensa prescribing information. Genentech, Inc. April 2024. |
|
5 |
Alunbrig prescribing information. Takeda Pharmaceuticals America, Inc. October 2024. |
|
6 |
Ayvakit prescribing information. Blueprint Medicines Corp. November 2024. |
|
7 |
Balversa prescribing information. Janssen Products, LP. October 2024. |
|
8 |
Besremi prescribing information. Pharmaessentia USA. April 2024. |
|
9 |
Bosulif prescribing information. Pfizer Inc. December 2024. |
|
10 |
Braftovi prescribing information. Array BioPharma Inc. March 2025. |
|
11 |
Brukinsa prescribing information. BeOne Medicines USA, Inc. January 2025. |
|
12 |
Cabometyx prescribing information. Exelixis, Inc. March 2025. |
|
13 |
Calquence prescribing information. AstraZeneca Pharmaceuticals LP. January 2025. |
|
14 |
Caprelsa prescribing information. Genzyme Corporation. May 2025. |
|
15 |
Cometriq prescribing information. Exelixis, Inc. August 2023. |
|
16 |
Copiktra prescribing information. Secura Bio, Inc. July 2024. |
|
17 |
Cotellic prescribing information. Genentech, Inc. May 2023. |
|
18 |
Daurismo prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2024. |
|
19 |
Erivedge prescribing information. Genentech, Inc. March 2023. |
|
20 |
Erleada prescribing information. Janssen Products, LP. August 2024. |
|
21 |
Itovebi prescribing information. Genentech, Inc. January 2025. |
|
22 |
Danziten prescribing information. Azurity Pharmaceuticals, Inc. November 2024. |
|
23 |
Fotivda prescribing information. Aveo Pharmaceuticals, Inc. January 2025. |
|
24 |
Gavreto prescribing information. Genentech Inc. March 2024. |
|
25 |
Gilotrif prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. April 2022. |
|
26 |
Gleevec prescribing information. Novartis Pharmaceuticals Corporation. March 2024. |
|
27 |
Hycamtin prescribing information. Novartis Pharmaceuticals Corporation. September 2018. |
|
28 |
Ibrance prescribing information. Pfizer Inc. April 2025. |
|
29 |
Iclusig prescribing information. Takeda Pharmaceuticals America, Inc. September 2024. |
|
30 |
Idhifa prescribing information. Celgene Corporation. January 2025. |
|
31 |
Imbruvica prescribing information. Pharmacyclics LLC. December 2024. |
|
32 |
Inlyta prescribing information. Pfizer Laboratories Div Pfizer Inc. July 2024. |
|
33 |
Inqovi prescribing information. Taiho Pharmaceutical Co., LTD. October 2024. |
|
34 |
Inrebic prescribing information. Celgene Corporation. May 2025. |
|
35 |
Iressa prescribing information. AstraZeneca Pharmaceuticals LP. February 2023. |
|
36 |
Jakafi prescribing information. Incyte Corporation. June 2025. |
|
37 |
Kisqali Femara Pack prescribing information. Novartis Pharmaceuticals Corporation. September 2024. |
|
38 |
Kisqali prescribing information. Novartis Pharmaceuticals Corporation. September 2024. |
|
39 |
Koselugo prescribing information. AstraZeneca Pharmaceuticals LP. September 2025. |
|
40 |
Lenvima prescribing information. Eisai Inc. January 2025. |
|
41 |
Lonsurf prescribing information. Taiho Pharmaceutical Co., Ltd. August 2023. |
|
42 |
Lorbrena prescribing information. Pfizer Laboratories Div Pfizer Inc. August 2024. |
|
43 |
Lumakras prescribing information. Amgen Inc. January 2025. |
|
44 |
Lynparza prescribing information. AstraZeneca Pharmaceuticals LP. November 2023. |
|
45 |
Lysodren prescribing information. HRA Pharma Rare Diseases. October 2024. |
|
46 |
Matulane prescribing information. Leadiant Biosciences. September 2024. |
|
47 |
Mekinist prescribing information. Novartis Pharmaceuticals Corporation. April 2025. |
|
48 |
Mektovi prescribing information. Array BioPharma Inc. March 2025. |
|
49 |
Nerlynx prescribing information. Puma Biotechnology, Inc. March 2022. |
|
50 |
Nexavar prescribing information. Bayer HealthCare Pharmaceuticals Inc. August 2023. |
|
51 |
Ninlaro prescribing information. Takeda Pharmaceuticals America, Inc. July 2024. |
|
52 |
Nubeqa prescribing information. Bayer HealthCare Pharmaceuticals Inc. June 2025. |
|
53 |
Odomzo prescribing information. Sun Pharmaceutical Industries, Inc. August 2023. |
|
54 |
Onureg prescribing information. Celgene Corporation. October 2022. |
|
55 |
Orgovyx prescribing information. Sumitomo Pharma America, Inc. October 2024. |
|
56 |
Pemazyre prescribing information. Incyte Corporation. June 2025. |
|
57 |
Piqray prescribing information. Novartis Pharmaceuticals Corp. January 2024. |
|
58 |
Pomalyst prescribing information. Celgene Corporation. February 2025. |
|
59 |
Qinlock prescribing information. Deciphera Pharmaceuticals, LLC. May 2025. |
|
60 |
Retevmo prescribing information. Eli Lilly and Company. December 2024. |
|
61 |
Revlimid prescribing information. Celgene Corporation. March 2023. |
|
62 |
Rozlytrek prescribing information. Genentech USA, Inc. January 2024. |
|
63 |
Rubraca prescribing information. Clovis Oncology, Inc. December 2022. |
|
64 |
Rydapt prescribing information. Novartis Pharmaceuticals Corporation. May 2023. |
|
65 |
Scemblix prescribing information. Novartis Pharmaceuticals Corporation. October 2024. |
|
66 |
Sprycel prescribing information. E.R. Squibb & Sons, L.L.C. July 2024. |
|
67 |
Stivarga prescribing information. Bayer Healthcare Pharmaceuticals Inc. February 2025. |
|
68 |
Sutent prescribing information. Pfizer Laboratories Div Pfizer Inc. August 2021. |
|
69 |
Tabrecta prescribing information. Novartis Pharmaceuticals Corp. March 2024. |
|
70 |
Tafinlar prescribing information. Novartis Pharmaceuticals Corporation. April 2025. |
|
71 |
Tagrisso prescribing information. AstraZeneca Pharmaceuticals LP. September 2024. |
|
72 |
Talzenna prescribing information. Pfizer Laboratories Div Pfizer Inc. June 2025. |
|
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. August 2024. |
|
77 |
Tazverik prescribing information. Epizyme Inc. August 2024. |
|
78 |
Temozolomide prescribing information. Accord Healthcare, Inc. June 2024. |
|
79 |
Tepmetko prescribing information. EMD Serono, Inc. February 2024. |
|
80 |
Thalomid prescribing information. Celgene Corporation. March 2023. |
|
81 |
Tibsovo prescribing information. Servier Pharmaceuticals LLC, Inc. October 2023. |
|
82 |
Tretinoin prescribing information. Glenmark Pharmaceuticals, Inc, USA. April 2023. |
|
83 |
Avmapki Fakzynja Co-Pack prescribing information. Verastem, Inc. May 2025. |
|
84 |
Tukysa prescribing information. Seagen Inc. January 2023. |
|
85 |
Turalio prescribing information. Daiichi Sankyo, Inc. January 2025. |
|
86 |
Tykerb prescribing information. Novartis Pharmaceuticals Corporation. March 2022. |
|
87 |
Revuforj prescribing information. Syndax Pharmaceuticals, Inc. April 2025. |
|
88 |
Venclexta prescribing information. AbbVie Inc. July 2024. |
|
89 |
Verzenio prescribing information. Eli Lilly and Company. February 2025. |
|
90 |
Vitrakvi prescribing information. Bayer HealthCare Pharmaceuticals Inc. April 2025. |
|
91 |
Vizimpro prescribing information. Pfizer Laboratories Div Pfizer Inc. December 2020. |
|
92 |
Votrient prescribing information. Novartis Pharmaceuticals Corporation. January 2024. |
|
93 |
Welireg prescribing information. Merck Sharp & Dohme LLC. May 2025. |
|
94 |
Xalkori prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2023. |
|
95 |
Xeloda prescribing information. Genentech, Inc. April 2023. |
|
96 |
Xospata prescribing information. Astellas Pharma US, Inc. January 2022. |
|
97 |
Xpovio prescribing information. Karyopharm Therapeutics Inc. March 2023. |
|
98 |
Xtandi prescribing information. Astellas Pharma US, Inc. March 2025. |
|
99 |
Yonsa prescribing information. Sun Pharmaceuticals Industries, Inc. March 2022. |
|
100 |
Phyrago prescribing information. Nanocopoeia. December 2024. |
|
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. November 2024. |
|
107 |
Lytgobi prescribing information. Taiho Pharmaceutical Co., LTD. April 2024. |
|
108 |
Rezlidhia prescribing information. Rigel Pharmaceuticals, Inc. April 2025. |
|
109 |
Krazati prescribing information. Mirati Therapeutics, Inc. June 2024. |
|
110 |
Jaypirca prescribing information. Eli Lilly and Company. June 2024. |
|
111 |
Orserdu prescribing information. Stemline Therapeutics, Inc. November 2023. |
|
112 |
Zejula prescribing information. GlaxoSmithKline. June 2025. |
|
113 |
Vanflyta prescribing information. Daiichi Sankyo Inc. June 2024. |
|
114 |
Akeega prescribing information. Janssen Biotech, Inc. August 2024. |
|
115 |
Ojjaara prescribing information. GlaxoSmithKline LLC. April 2025. |
|
116 |
Fruzaqla prescribing information. Takeda Pharmaceuticals America, Inc. February 2025 |
|
117 |
Truqap prescribing information. AstraZeneca Pharmaceuticals LP. February 2025. |
|
118 |
Augtyro prescribing information. E.R Squibb & Sons, LLC. June 2024. |
|
119 |
Ogsiveo prescribing information. SpringWorks Therapeutics, Inc. April 2024. |
|
120 |
Iwilfin prescribing information. US Worldmeds (USWM), LCC. November 2024. |
|
121 |
Ojemda prescribing information. Day One Biopharmaceuticals, Inc. April 2025. |
|
122 |
Imkeldi prescribing information. Shorla Oncology, Inc. November 2024. |
|
123 |
Gomekli prescribing information. SpringWorks Therapeutics, Inc. February 2025. |
|
124 |
Romvimza prescribing information. Deciphera Pharmaceuticals, LLC. February 2025. |
|
125 |
Ensacove prescribing information. Xcovery Holdings, Inc. December 2024. |
|
126 |
Ibtrozi prescribing information. Nuvation Bio, Inc. June 2025. |
|
127 |
Nilotinib d-tartrate prescribing information. Cipla USA, Inc. February 2025. |
|
128 |
Hernexeos prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. August 2025. |
|
129 |
Modeyso prescribing information. Jazz Pharmaceuticals, Inc. August 2025. |
|
130 |
Inluriyo prescribing information. Eli Lilly and Company. September 2025. |
POLICY AGENT SUMMARY PRIOR AUTHORIZATION
|
Target Brand Agent(s) |
Target Generic Agent(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
|
||||||
|
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 MG ; 500 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
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 |
|
|
|
Avmapki fakzynja co-pack |
avutometinib cap |
0.8 & 200 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 |
|
|
|
Truqap |
capivasertib tab therapy pack |
160 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 |
|
|
|
Cotellic |
cobimetinib fumarate tab |
20 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 |
|
|
|
Nubeqa |
darolutamide tab |
300 MG |
M ; N ; O ; Y |
N |
|
|
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
M ; N ; O ; Y |
N |
|
|
|
Modeyso |
dordaviprone hcl cap |
125 MG |
M ; N ; O ; Y |
N |
|
|
|
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
|
Orserdu |
elacestrant hydrochloride tab |
345 MG ; 86 MG |
M ; N ; O ; Y |
N |
|
|
|
Idhifa |
enasidenib mesylate tab |
100 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Braftovi |
encorafenib cap |
75 MG |
M ; N ; O ; Y |
N |
|
|
|
Ensacove |
ensartinib hcl cap |
100 MG ; 25 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 |
|
|
|
Afinitor |
everolimus tab |
10 MG ; 2.5 MG ; 5 MG ; 7.5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Afinitor |
Everolimus Tab 10 MG |
10 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Afinitor |
Everolimus Tab 5 MG |
5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Afinitor disperz |
everolimus tab for oral susp |
2 MG ; 3 MG ; 5 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Inrebic |
fedratinib hcl cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
|
Lytgobi |
futibatinib tab therapy pack |
4 MG |
M ; N ; O ; Y |
N |
|
|
|
Iressa |
gefitinib tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
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 ; 70 MG ; 70 MG/ML |
M ; N ; O ; Y |
N |
|
|
|
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
M ; N ; O ; Y |
N |
|
|
|
Gleevec ; Imkeldi |
imatinib mesylate oral soln ; imatinib mesylate tab |
100 MG ; 400 MG ; 80 MG/ML |
M ; N ; O ; Y |
N ; O ; Y |
|
|
|
Inluriyo |
imlunestrant tosylate tab |
200 MG |
M ; N ; O ; Y |
N |
|
|
|
Itovebi |
inavolisib tab |
3 MG ; 9 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 |
|
|
|
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 |
|
|
|
Lazcluze |
lazertinib mesylate tab |
240 MG ; 80 MG |
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 |
|
|
|
Rydapt |
midostaurin cap |
25 MG |
M ; N ; O ; Y |
N |
|
|
|
Gomekli |
mirdametinib cap |
1 MG ; 2 MG |
M ; N ; O ; Y |
N |
|
|
|
Gomekli |
mirdametinib tab for oral susp |
1 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 |
|
|
|
Nilotinib |
nilotinib d-tartrate cap |
150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Danziten |
nilotinib tartrate tab |
71 MG ; 95 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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Pemazyre |
pemigatinib tab |
13.5 MG ; 4.5 MG ; 9 MG |
M ; N ; O ; Y |
N |
|
|
|
Turalio |
pexidartinib hcl cap |
125 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 |
|
|
|
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 |
|
|
|
Stivarga |
regorafenib tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
|
Orgovyx |
relugolix tab |
120 MG |
M ; N ; O ; Y |
N |
|
|
|
Revuforj |
revumenib citrate tab |
110 MG ; 160 MG ; 25 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 |
|
|
|
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 |
10 MG ; 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 tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
|
Koselugo |
selumetinib sulfate cap |
10 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
|
Koselugo |
selumetinib sulfate cap sprinkle |
5 MG ; 7.5 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 ; 240 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 |
|
|
|
Ibtrozi |
taletrectinib adipate cap |
200 MG |
M ; N ; O ; Y |
N |
|
|
|
Tazverik |
tazemetostat hbr tab |
200 MG |
M ; N ; O ; Y |
N |
|
|
|
|
temozolomide cap |
100 MG ; 140 MG ; 180 MG ; 20 MG ; 250 MG ; 5 MG |
M ; N ; O ; Y |
Y |
|
|
|
Tepmetko |
tepotinib hcl tab |
225 MG |
M ; N ; O ; Y |
N |
|
|
|
Thalomid |
thalidomide cap |
100 MG ; 150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Fotivda |
tivozanib hcl cap |
0.89 MG ; 1.34 MG |
M ; N ; O ; Y |
N |
|
|
|
Hycamtin |
topotecan hcl cap |
0.25 MG ; 1 MG |
M ; N ; O ; Y |
N |
|
|
|
Mekinist |
trametinib dimethyl sulfoxide 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 |
|
|
|
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 |
|
|
|
Romvimza |
vimseltinib cap |
14 MG ; 20 MG ; 30 MG |
M ; N ; O ; Y |
N |
|
|
|
Erivedge |
vismodegib cap |
150 MG |
M ; N ; O ; Y |
N |
|
|
|
Voranigo |
vorasidenib tab |
10 MG ; 40 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 ; zanubrutinib tab |
160 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
|
Hernexeos |
zongertinib tab |
60 MG |
M ; N ; O ; Y |
N |
|
|
|
Augtyro |
repotrectinib cap |
160 MG ; 40 MG |
M ; N ; O ; Y |
N |
|
|
|
Calquence |
acalabrutinib maleate tab |
100 MG |
M ; N ; O ; Y |
N |
|
|
|
Fruzaqla |
fruquintinib cap |
1 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
|
Inlyta |
axitinib tab |
1 MG ; 5 MG |
M ; N ; O ; Y |
N |
|
|
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
M ; N ; O ; Y |
N |
|
|
|
Iressa |
gefitinib tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Iwilfin |
eflornithine hcl tab |
192 MG |
M ; N ; O ; Y |
N |
|
|
|
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
M ; N ; O ; Y |
N |
|
|
|
Nerlynx |
neratinib maleate tab |
40 MG |
M ; N ; O ; Y |
N |
|
|
|
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG ; 150 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Ojemda |
tovorafenib for oral susp ; tovorafenib tab |
100 MG ; 25 MG/ML |
M ; N ; O ; Y |
N |
|
|
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
M ; N ; O ; Y |
N |
|
|
|
Qinlock |
ripretinib tab |
50 MG |
M ; N ; O ; Y |
N |
|
|
|
Retevmo |
selpercatinib cap ; selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 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 ; O ; Y |
|
|
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
M ; N ; O ; Y |
N |
|
|
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
M ; N ; O ; Y |
N |
|
|
|
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Turalio |
pexidartinib hcl cap |
125 MG |
M ; N ; O ; Y |
N |
|
|
|
Tykerb |
lapatinib ditosylate tab |
250 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG ; 26.5 MG |
M ; N ; O ; Y |
N |
|
|
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
M ; N ; O ; Y |
N |
|
|
|
Vonjo |
pacritinib citrate cap |
100 MG |
M ; N ; O ; Y |
N |
|
|
|
Votrient |
pazopanib hcl tab |
200 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
Xalkori |
crizotinib cap ; crizotinib cap sprinkle |
150 MG ; 20 MG ; 200 MG ; 250 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
|
Xospata |
gilteritinib fumarate tablet |
40 MG |
M ; N ; O ; Y |
N |
|
|
|
Zykadia |
ceritinib cap ; ceritinib tab |
150 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 |
|
|
|||||||||
|
|
Erlotinib HCl Tab |
25 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
|
Erlotinib HCl Tab |
150 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Afinitor |
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 |
|
|
|
|
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 |
1 |
Pack |
180 |
DAYS |
|
|
|
|
Augtyro |
repotrectinib cap |
40 MG |
240 |
Capsules |
30 |
DAYS |
|
|
|
|
Augtyro |
repotrectinib cap |
160 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Avmapki fakzynja co-pack |
avutometinib cap |
0.8 & 200 MG |
66 |
Tablets |
28 |
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 |
400 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Bosulif |
Bosutinib Tab |
500 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Braftovi |
encorafenib cap |
75 MG |
180 |
Capsules |
30 |
DAYS |
|
|
|
|
Brukinsa |
Zanubrutinib Cap |
80 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|
Brukinsa |
zanubrutinib tab |
160 MG |
60 |
Tablets |
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 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 |
|
|
|
|
Danziten |
nilotinib tartrate tab |
71 MG |
112 |
Tablets |
28 |
DAYS |
|
|
|
|
Danziten |
nilotinib tartrate tab |
95 MG |
112 |
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 |
|
|
|
|
Ensacove |
ensartinib hcl cap |
25 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Ensacove |
ensartinib hcl cap |
100 MG |
60 |
Capsules |
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 |
Tablets |
30 |
DAYS |
|
|
|
|
Gomekli |
mirdametinib cap |
1 MG |
168 |
Capsules |
28 |
DAYS |
|
|
|
|
Gomekli |
mirdametinib cap |
2 MG |
84 |
Capsules |
28 |
DAYS |
|
|
|
|
Gomekli |
mirdametinib tab for oral susp |
1 MG |
168 |
Tablets |
28 |
DAYS |
|
|
|
|
Hernexeos |
zongertinib tab |
60 MG |
180 |
Tablets |
60 |
DAYS |
|
|
|
|
Ibrance |
palbociclib cap |
100 MG ; 125 MG ; 75 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
|
Ibrance |
palbociclib tab |
100 MG ; 125 MG ; 75 MG |
21 |
Tablets |
28 |
DAYS |
|
|
|
|
Ibtrozi |
taletrectinib adipate cap |
200 MG |
90 |
Capsules |
30 |
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 |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Imkeldi |
imatinib mesylate oral soln |
80 MG/ML |
280 |
mLs |
28 |
DAYS |
|
|
|
|
Inluriyo |
imlunestrant tosylate tab |
200 MG |
56 |
Tablets |
28 |
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 |
|
|
|
|
Itovebi |
inavolisib tab |
3 MG |
56 |
Tablets |
28 |
DAYS |
|
|
|
|
Itovebi |
inavolisib tab |
9 MG |
28 |
Tablets |
28 |
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 |
|
|
|
|
Koselugo |
selumetinib sulfate cap sprinkle |
5 MG |
7 |
Bottles |
30 |
DAYS |
|
|
|
|
Koselugo |
selumetinib sulfate cap sprinkle |
7.5 MG |
4 |
Bottles |
30 |
DAYS |
|
|
|
|
Krazati |
Adagrasib Tab |
200 MG |
180 |
Tablets |
30 |
DAYS |
|
|
|
|
Lazcluze |
lazertinib mesylate tab |
80 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Lazcluze |
lazertinib mesylate tab |
240 MG |
30 |
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 |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Lorbrena |
Lorlatinib Tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Lumakras |
sotorasib tab |
240 MG |
120 |
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 |
|
|
|
|
Modeyso |
dordaviprone hcl cap |
125 MG |
20 |
Capsules |
28 |
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 |
|
|
|
|
Nilotinib |
nilotinib d-tartrate cap |
50 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|
Nilotinib |
nilotinib d-tartrate cap |
150 MG |
120 |
Capsules |
30 |
DAYS |
|
|
|
|
Nilotinib |
nilotinib d-tartrate cap |
200 MG |
120 |
Capsules |
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 |
28 |
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 |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
20 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
50 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
70 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
80 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
100 MG |
30 |
Tablets |
30 |
DAYS |
|
|
|
|
Phyrago ; Sprycel |
Dasatinib Tab |
140 MG |
30 |
Tablets |
30 |
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 |
|
|
|
|
Qinlock |
Ripretinib Tab |
50 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Retevmo |
Selpercatinib Cap |
40 MG |
90 |
Capsules |
30 |
DAYS |
|
|
|
|
Retevmo |
Selpercatinib Cap |
80 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Retevmo |
selpercatinib tab |
40 MG |
90 |
Tablets |
30 |
DAYS |
|
|
|
|
Retevmo |
selpercatinib tab |
80 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Retevmo |
selpercatinib tab |
120 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Retevmo |
selpercatinib tab |
160 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Cap 10 MG |
10 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Cap 15 MG |
15 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Cap 20 MG |
20 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Cap 25 MG |
25 MG |
21 |
Capsules |
28 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Cap 5 MG |
5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Revlimid |
Lenalidomide Caps 2.5 MG |
2.5 MG |
30 |
Capsules |
30 |
DAYS |
|
|
|
|
Revuforj |
revumenib citrate tab |
25 MG |
240 |
Tablets |
30 |
DAYS |
|
|
|
|
Revuforj |
revumenib citrate tab |
110 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Revuforj |
revumenib citrate tab |
160 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Rezlidhia |
Olutasidenib Cap |
150 MG |
60 |
Capsules |
30 |
DAYS |
|
|
|
|
Romvimza |
vimseltinib cap |
14 MG |
8 |
Capsules |
28 |
DAYS |
|
|
|
|
Romvimza |
vimseltinib cap |
20 MG |
8 |
Capsules |
28 |
DAYS |
|
|
|
|
Romvimza |
vimseltinib cap |
30 MG |
8 |
Capsules |
28 |
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 |
240 |
Tablets |
30 |
DAYS |
|
|
|
|
Scemblix |
asciminib hcl tab |
100 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Stivarga |
regorafenib tab |
40 MG |
84 |
Tablets |
28 |
DAYS |
|
|
|
|
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 |
112 |
Tablets |
28 |
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 |
100 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 |
|
|
|
|
Tepmetko |
Tepotinib HCl Tab |
225 MG |
60 |
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 |
|
|
|
|
Truqap |
capivasertib tab therapy pack |
160 MG |
64 |
Tablets |
28 |
DAYS |
|
|
|
|
Truqap |
capivasertib tab therapy pack |
200 MG |
64 |
Tablets |
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 |
|
|
|
|
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 |
|
|
|
|
Voranigo |
vorasidenib tab |
10 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
|
Voranigo |
vorasidenib tab |
40 MG |
30 |
Tablets |
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 |
10 MG |
16 |
Tablets |
28 |
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 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 MG |
120 |
Tablets |
30 |
DAYS |
|
|
|
|
Zytiga |
Abiraterone Acetate Tab 500 MG |
500 MG |
60 |
Tablets |
30 |
DAYS |
|
|
|
CLIENT SUMMARY – PRIOR AUTHORIZATION
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
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 ; SourceRx-Performance |
|
|
tretinoin cap |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor |
everolimus tab |
10 MG ; 2.5 MG ; 5 MG ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor |
Everolimus Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor |
Everolimus Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor disperz |
everolimus tab for oral susp |
2 MG ; 3 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG ; 50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alunbrig |
brigatinib tab |
180 MG ; 30 MG ; 90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Augtyro |
repotrectinib cap |
160 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Avmapki fakzynja co-pack |
avutometinib cap |
0.8 & 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Balversa |
erdafitinib tab |
3 MG ; 4 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Besremi |
ropeginterferon alfa- |
500 MCG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
bosutinib cap ; bosutinib tab |
100 MG ; 400 MG ; 50 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Braftovi |
encorafenib cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Brukinsa |
zanubrutinib cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Brukinsa |
zanubrutinib cap ; zanubrutinib tab |
160 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cabometyx |
cabozantinib s-malate tab |
20 MG ; 40 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Calquence |
acalabrutinib maleate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Caprelsa |
vandetanib tab |
100 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cotellic |
cobimetinib fumarate tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Danziten |
nilotinib tartrate tab |
71 MG ; 95 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Daurismo |
glasdegib maleate tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ensacove |
ensartinib hcl cap |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Erivedge |
vismodegib cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Erleada |
apalutamide tab |
240 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fotivda |
tivozanib hcl cap |
0.89 MG ; 1.34 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fruzaqla |
fruquintinib cap |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gleevec ; Imkeldi |
imatinib mesylate oral soln ; imatinib mesylate tab |
100 MG ; 400 MG ; 80 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gomekli |
mirdametinib cap |
1 MG ; 2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gomekli |
mirdametinib tab for oral susp |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Hernexeos |
zongertinib tab |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Hycamtin |
topotecan hcl cap |
0.25 MG ; 1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibrance |
palbociclib cap |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibrance |
palbociclib cap ; palbociclib tab |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibtrozi |
taletrectinib adipate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iclusig |
ponatinib hcl tab |
10 MG ; 15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Idhifa |
enasidenib mesylate tab |
100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imbruvica |
ibrutinib cap ; ibrutinib oral susp ; ibrutinib tab |
140 MG ; 280 MG ; 420 MG ; 70 MG ; 70 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inluriyo |
imlunestrant tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inlyta |
axitinib tab |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inlyta |
axitinib tab |
1 MG ; 5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inrebic |
fedratinib hcl cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Itovebi |
inavolisib tab |
3 MG ; 9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iwilfin |
eflornithine hcl tab |
192 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Jaypirca |
pirtobrutinib tab |
100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Kisqali |
ribociclib succinate tab pack |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Koselugo |
selumetinib sulfate cap |
10 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Koselugo |
selumetinib sulfate cap sprinkle |
5 MG ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Krazati |
adagrasib tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lazcluze |
lazertinib mesylate tab |
240 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG ; 20-8.19 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lorbrena |
lorlatinib tab |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lumakras |
sotorasib tab |
120 MG ; 240 MG ; 320 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lynparza |
olaparib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lysodren |
mitotane tab |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lytgobi |
futibatinib tab therapy pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Matulane |
procarbazine hcl cap |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mekinist |
trametinib dimethyl sulfoxide tab |
0.5 MG ; 2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mektovi |
binimetinib tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Modeyso |
dordaviprone hcl cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nerlynx |
neratinib maleate tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nerlynx |
neratinib maleate tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nexavar |
sorafenib tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nilotinib |
nilotinib d-tartrate cap |
150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nubeqa |
darolutamide tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Odomzo |
sonidegib phosphate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG ; 150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojemda |
tovorafenib for oral susp ; tovorafenib tab |
100 MG ; 25 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojjaara |
momelotinib dihydrochloride tab |
100 MG ; 150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Onureg |
azacitidine tab |
200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Orgovyx |
relugolix tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Orserdu |
elacestrant hydrochloride tab |
345 MG ; 86 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Pemazyre |
pemigatinib tab |
13.5 MG ; 4.5 MG ; 9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Qinlock |
ripretinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Qinlock |
ripretinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib cap |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib cap ; selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib tab |
120 MG ; 160 MG ; 40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Revuforj |
revumenib citrate tab |
110 MG ; 160 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rezlidhia |
olutasidenib cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Romvimza |
vimseltinib cap |
14 MG ; 20 MG ; 30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rozlytrek |
entrectinib cap |
100 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rozlytrek |
entrectinib pellet pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rubraca |
rucaparib camsylate tab |
200 MG ; 250 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rydapt |
midostaurin cap |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Scemblix |
asciminib hcl tab |
100 MG ; 20 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Stivarga |
regorafenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tarceva |
erlotinib hcl tab |
100 MG ; 150 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Targretin |
bexarotene cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Targretin |
Bexarotene Gel 1% |
1 % |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tazverik |
tazemetostat hbr tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tepmetko |
tepotinib hcl tab |
225 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Thalomid |
thalidomide cap |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tibsovo |
ivosidenib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab |
160 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab therapy pack |
160 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tukysa |
tucatinib tab |
150 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Turalio |
pexidartinib hcl cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Turalio |
pexidartinib hcl cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tykerb |
lapatinib ditosylate tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tykerb |
lapatinib ditosylate tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG ; 26.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Venclexta |
venetoclax tab |
10 MG ; 100 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Venclexta starting pack |
venetoclax tab therapy starter pack |
10 & 50 & 100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vitrakvi |
larotrectinib sulfate cap |
100 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vitrakvi |
larotrectinib sulfate oral soln |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vonjo |
pacritinib citrate cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Voranigo |
vorasidenib tab |
10 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Votrient |
pazopanib hcl tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Votrient |
pazopanib hcl tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Welireg |
belzutifan tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Xeloda |
capecitabine tab |
150 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xospata |
gilteritinib fumarate tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xospata |
gilteritinib fumarate tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio ; Xpovio 60 mg twice weekly ; Xpovio 80 mg twice weekly |
selinexor tab therapy pack |
10 MG ; 20 MG ; 40 MG ; 50 MG ; 60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xtandi |
enzalutamide cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xtandi |
enzalutamide tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Yonsa |
abiraterone acetate micronized tab |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zejula |
niraparib tosylate tab |
100 MG ; 200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zelboraf |
vemurafenib tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zolinza |
vorinostat cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zykadia |
ceritinib cap ; ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zykadia |
ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zytiga |
abiraterone acetate tab |
250 MG ; 500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
CLIENT SUMMARY – QUANTITY LIMITS
|
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|
Erlotinib HCl Tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
|
Erlotinib HCl Tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor |
everolimus tab |
10 MG ; 2.5 MG ; 5 MG ; 7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor disperz |
Everolimus Tab for Oral Susp 2 MG |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor disperz |
Everolimus Tab for Oral Susp 3 MG |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Afinitor disperz |
Everolimus Tab for Oral Susp 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
100-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Akeega |
niraparib tosylate-abiraterone acetate tab |
50-500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alecensa |
alectinib hcl cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alunbrig |
Brigatinib Tab |
90 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alunbrig |
Brigatinib Tab |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alunbrig |
Brigatinib Tab |
180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Alunbrig |
Brigatinib Tab Initiation Therapy Pack |
90 & 180 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Augtyro |
repotrectinib cap |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Augtyro |
repotrectinib cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Avmapki fakzynja co-pack |
avutometinib cap |
0.8 & 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ayvakit |
avapritinib tab |
100 MG ; 200 MG ; 25 MG ; 300 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Balversa |
Erdafitinib Tab 3 MG |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Balversa |
Erdafitinib Tab 4 MG |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Balversa |
Erdafitinib Tab 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Besremi |
Ropeginterferon alfa- |
500 MCG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
bosutinib cap |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
bosutinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
Bosutinib Tab |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
Bosutinib Tab |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Bosulif |
Bosutinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Braftovi |
encorafenib cap |
75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Brukinsa |
Zanubrutinib Cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Brukinsa |
zanubrutinib tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cabometyx |
Cabozantinib S-Malate Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cabometyx |
Cabozantinib S-Malate Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cabometyx |
Cabozantinib S-Malate Tab |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Calquence |
acalabrutinib maleate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Caprelsa |
Vandetanib Tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Caprelsa |
Vandetanib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cometriq |
Cabozantinib S-Mal Cap |
3 x 20 MG & 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cometriq |
Cabozantinib S-Mal Cap |
80 & 20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cometriq |
Cabozantinib S-Malate Cap |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Copiktra |
duvelisib cap |
15 MG ; 25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Cotellic |
cobimetinib fumarate tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Danziten |
nilotinib tartrate tab |
71 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Danziten |
nilotinib tartrate tab |
95 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Daurismo |
Glasdegib Maleate Tab 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Daurismo |
Glasdegib Maleate Tab 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ensacove |
ensartinib hcl cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ensacove |
ensartinib hcl cap |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Erivedge |
Vismodegib Cap 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Erleada |
apalutamide tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Erleada |
Apalutamide Tab 60 MG |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fotivda |
Tivozanib HCl Cap |
0.89 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fotivda |
Tivozanib HCl Cap |
1.34 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fruzaqla |
fruquintinib cap |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Fruzaqla |
fruquintinib cap |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gavreto |
pralsetinib cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gilotrif |
afatinib dimaleate tab |
20 MG ; 30 MG ; 40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gleevec |
Imatinib Mesylate Tab |
400 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gleevec |
Imatinib Mesylate Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gomekli |
mirdametinib cap |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gomekli |
mirdametinib cap |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Gomekli |
mirdametinib tab for oral susp |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Hernexeos |
zongertinib tab |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibrance |
palbociclib cap |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibrance |
palbociclib tab |
100 MG ; 125 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ibtrozi |
taletrectinib adipate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iclusig |
Ponatinib HCl Tab |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iclusig |
Ponatinib HCl Tab |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iclusig |
Ponatinib HCl Tab |
45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iclusig |
Ponatinib HCl Tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Idhifa |
Enasidenib Mesylate Tab 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Idhifa |
Enasidenib Mesylate Tab 50 MG (Base Equivalent) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imbruvica |
Ibrutinib Cap |
140 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imbruvica |
Ibrutinib Cap |
70 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imbruvica |
Ibrutinib Oral Susp |
70 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imbruvica |
ibrutinib tab |
140 MG ; 280 MG ; 420 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Imkeldi |
imatinib mesylate oral soln |
80 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inluriyo |
imlunestrant tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inlyta |
Axitinib Tab |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inlyta |
Axitinib Tab |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inqovi |
decitabine-cedazuridine tab |
35-100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Inrebic |
Fedratinib HCl Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iressa |
gefitinib tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Itovebi |
inavolisib tab |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Itovebi |
inavolisib tab |
9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Iwilfin |
eflornithine hcl tab |
192 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Jaypirca |
pirtobrutinib tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Jaypirca |
pirtobrutinib tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Kisqali |
Ribociclib Succinate Tab Pack 200 MG Daily Dose |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Koselugo |
Selumetinib Sulfate Cap 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Koselugo |
Selumetinib Sulfate Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Koselugo |
selumetinib sulfate cap sprinkle |
7.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Koselugo |
selumetinib sulfate cap sprinkle |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Krazati |
Adagrasib Tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lazcluze |
lazertinib mesylate tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lazcluze |
lazertinib mesylate tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lenvima 10 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lenvima 12mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lenvima 14 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 & 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Lenvima 20 mg daily dose |
Lenvatinib Cap Therapy Pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Lenvima 4 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lenvima 8 mg daily dose |
Lenvatinib Cap Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lonsurf |
trifluridine-tipiracil tab |
20-8.19 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lonsurf |
trifluridine-tipiracil tab |
15-6.14 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lorbrena |
Lorlatinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lorbrena |
Lorlatinib Tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lumakras |
sotorasib tab |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lumakras |
sotorasib tab |
320 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lumakras |
Sotorasib Tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lynparza |
olaparib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Lytgobi |
Futibatinib Tab Therapy Pack |
4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mekinist |
trametinib dimethyl sulfoxide for soln |
0.05 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent) |
0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mekinist |
Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent) |
2 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Mektovi |
binimetinib tab |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Modeyso |
dordaviprone hcl cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nerlynx |
Neratinib Maleate Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nexavar |
Sorafenib Tosylate Tab 200 MG (Base Equivalent) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nilotinib |
nilotinib d-tartrate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nilotinib |
nilotinib d-tartrate cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nilotinib |
nilotinib d-tartrate cap |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ninlaro |
ixazomib citrate cap |
2.3 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Nubeqa |
Darolutamide Tab 300 MG |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Odomzo |
sonidegib phosphate cap |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ogsiveo |
nirogacestat hydrobromide tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ogsiveo |
nirogacestat hydrobromide tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ogsiveo |
nirogacestat hydrobromide tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojemda |
tovorafenib for oral susp |
25 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojemda |
tovorafenib tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojjaara |
momelotinib dihydrochloride tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojjaara |
momelotinib dihydrochloride tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Ojjaara |
momelotinib dihydrochloride tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Onureg |
azacitidine tab |
200 MG ; 300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Orgovyx |
relugolix tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Orserdu |
elacestrant hydrochloride tab |
86 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Orserdu |
elacestrant hydrochloride tab |
345 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Pemazyre |
Pemigatinib Tab 13.5 MG |
13.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Pemazyre |
Pemigatinib Tab 4.5 MG |
4.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Pemazyre |
Pemigatinib Tab 9 MG |
9 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
140 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
70 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Phyrago ; Sprycel |
Dasatinib Tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Pomalyst |
pomalidomide cap |
1 MG ; 2 MG ; 3 MG ; 4 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Qinlock |
Ripretinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
Selpercatinib Cap |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
Selpercatinib Cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib tab |
120 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Retevmo |
selpercatinib tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Cap 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Cap 15 MG |
15 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Cap 20 MG |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Cap 5 MG |
5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revlimid |
Lenalidomide Caps 2.5 MG |
2.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revuforj |
revumenib citrate tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revuforj |
revumenib citrate tab |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Revuforj |
revumenib citrate tab |
110 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rezlidhia |
Olutasidenib Cap |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Romvimza |
vimseltinib cap |
30 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Romvimza |
vimseltinib cap |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Romvimza |
vimseltinib cap |
14 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rozlytrek |
Entrectinib Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rozlytrek |
Entrectinib Cap 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rozlytrek |
entrectinib pellet pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rubraca |
Rucaparib Camsylate Tab 200 MG (Base Equivalent) |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rubraca |
Rucaparib Camsylate Tab 250 MG (Base Equivalent) |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rubraca |
Rucaparib Camsylate Tab 300 MG (Base Equivalent) |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Rydapt |
Midostaurin Cap 25 MG |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Scemblix |
asciminib hcl tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Scemblix |
Asciminib HCl Tab |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Scemblix |
Asciminib HCl Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Stivarga |
regorafenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Sutent |
Sunitinib Malate Cap 12.5 MG (Base Equivalent) |
12.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Sutent |
Sunitinib Malate Cap 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Sutent |
Sunitinib Malate Cap 37.5 MG (Base Equivalent) |
37.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Sutent |
Sunitinib Malate Cap 50 MG (Base Equivalent) |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tabrecta |
capmatinib hcl tab |
150 MG ; 200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tafinlar |
dabrafenib mesylate cap |
50 MG ; 75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tafinlar |
dabrafenib mesylate tab for oral susp |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tagrisso |
osimertinib mesylate tab |
40 MG ; 80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
talazoparib tosylate cap |
0.35 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
Talazoparib Tosylate Cap |
0.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
talazoparib tosylate cap |
0.1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
Talazoparib Tosylate Cap |
0.75 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
Talazoparib Tosylate Cap 0.25 MG (Base Equivalent) |
0.25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Talzenna |
Talazoparib Tosylate Cap 1 MG (Base Equivalent) |
1 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tarceva |
Erlotinib HCl Tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tasigna |
nilotinib hcl cap |
150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tazverik |
tazemetostat hbr tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tepmetko |
Tepotinib HCl Tab |
225 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Thalomid |
Thalidomide Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Thalomid |
Thalidomide Cap 150 MG |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Thalomid |
Thalidomide Cap 200 MG |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Thalomid |
Thalidomide Cap 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tibsovo |
Ivosidenib Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab therapy pack |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Truqap |
capivasertib tab therapy pack |
160 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tukysa |
Tucatinib Tab |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tukysa |
Tucatinib Tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Turalio |
Pexidartinib HCl Cap |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Tykerb |
Lapatinib Ditosylate Tab |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vanflyta |
quizartinib dihydrochloride tab |
26.5 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vanflyta |
quizartinib dihydrochloride tab |
17.7 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Venclexta |
Venetoclax Tab 10 MG |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Venclexta |
Venetoclax Tab 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Venclexta |
Venetoclax Tab 50 MG |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Verzenio |
abemaciclib tab |
100 MG ; 150 MG ; 200 MG ; 50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vitrakvi |
Larotrectinib Sulfate Cap 100 MG (Base Equivalent) |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vitrakvi |
Larotrectinib Sulfate Cap 25 MG (Base Equivalent) |
25 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vitrakvi |
Larotrectinib Sulfate Oral Soln 20 MG/ML (Base Equivalent) |
20 MG/ML |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vizimpro |
dacomitinib tab |
15 MG ; 30 MG ; 45 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Vonjo |
Pacritinib Citrate Cap |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Voranigo |
vorasidenib tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Voranigo |
vorasidenib tab |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Votrient |
Pazopanib HCl Tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Welireg |
Belzutifan Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xalkori |
crizotinib cap |
200 MG ; 250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xalkori |
crizotinib cap sprinkle |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xalkori |
crizotinib cap sprinkle |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xalkori |
crizotinib cap sprinkle |
20 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xospata |
Gilteritinib Fumarate Tablet |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
selinexor tab therapy pack |
10 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
Selinexor Tab Therapy Pack |
60 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
Selinexor Tab Therapy Pack |
50 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xpovio |
Selinexor Tab Therapy Pack |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
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 ; SourceRx-Performance |
|
Xtandi |
enzalutamide cap |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xtandi |
Enzalutamide Tab |
80 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Xtandi |
Enzalutamide Tab |
40 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Yonsa |
abiraterone acetate tab 125 mg |
125 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zejula |
niraparib tosylate tab |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zejula |
niraparib tosylate tab |
200 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zejula |
niraparib tosylate tab |
300 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zelboraf |
Vemurafenib Tab 240 MG |
240 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zolinza |
Vorinostat Cap 100 MG |
100 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zydelig |
idelalisib tab |
100 MG ; 150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zykadia |
ceritinib tab |
150 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zytiga |
Abiraterone Acetate Tab 250 MG |
250 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
|
Zytiga |
Abiraterone Acetate Tab 500 MG |
500 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx ; SourceRx-Performance |
PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
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|
PA QL |
*Preferred Agents 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:
Compendia Allowed: NCCN 1 or 2A recommended use, AHFS, DrugDex level of evidence of 1 or 2A Length of Approval*: titration requests over the program quantity limit or Vitrakvi - up to 3 months; all other requests - up to 12 months *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:
Length of Approval: up to 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. |
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
|
|
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:
Length of Approval: up to 12 months |
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.