NOTE: Not all plans cover these drugs nor require preauthorization. Please refer to the member's Individual Policy (also known as Certificate of Coverage, Master Contract or Plan Document) for information regarding coverage determination.

**This list does not guarantee coverage and is subject to change.**

  • Abecma, idecabtagene vicleucel (Q2055) (medical)

  • Adstiladrin, nadofaragene firadenovec-vncg (J9029) (medical)

  • Afinitor (everolimus)

  • Akeega (niraparib/abiraterone acetate)

  • Alecensa (alectinib)

  • Alimta, pemetrexed (J9294, J9296, J9297, J9304, J9305, J9314, J9322,  J9323, J9324) (medical)

  • Aliqopa, copanlisib (J9057)  (medical)

  • Alunbrig (brigatinib)

  • Alymsys, bevacizumab-maly (Q5126) (medical)

  • Amtagvi, lifileucel (medical)

  • Anktiva, nogapendekin alfa Inbakicept-pmln (medical)

  • Arranon, nelarabine (J9261) (medical)

  • Arzerra, ofatumumab (J9302) (medical)

  • Asparlas, calaspargase pegol-mknl (J9118) (medical)

  • Augtyro (repotrectinib)

  • Avastin, bevacizumab (J9035) (medical)

  • Ayvakit (avapritinib)

  • Balversa (erdafitinib)

  • Bavencio, avelumab (J9023) (medical)

  • Beleodaq, belinostat (J9032) (medical)

  • Belrapzo, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059) (medical)

  • Bendeka, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059)  (medical)

  • Besponsa, inotuzumab ozogamicin (J9229) (medical)

  • Besremi (ropeginterferon alfa-2b-njft)

  • BiCNU, carmustine (J9050, J9052) (medical)

  • Blenrep, belantamab mafodotin-blmf (J9037) (medical)

  • Blincyto, blinatumomab (J9039) (medical)

  • Bosulif (bosutinib)

  • Braftovi (encorafenib)

  • Breyanzi, lisocabtagene maraleucel (Q2054) (medical)

  • Brukinsa (zanubrutinib)

  • Cabometyx (cabozantinib)

  • Calquence (acalabrutinib)

  • Camcevi, leuprolide (J1952) (medical)

  • Caprelsa (vandetanib)

  • Carvykti, ciltacabtagene autoleucel (Q2056) (medical)

  • Clolar, clofarabine (J9027) (medical)

  • Columvi, glofitamab-gxbm (J9286) (medical)

  • Cometriq (cabozantinib)

  • Copiktra (duvelisib)

  • Cosela, trilaciclib (J1448)** (medical)

  • Cosmegen, dactinomycin (J9120) (medical)

  • Cotellic (cobimetinib)

  • Cyramza, ramucirumab (J9308) (medical)

  • Dacogen, decitabine (J0893, J0894) (medical)

  • Danyelza, naxitamab-gqgk (J9348) (medical)

  • Darzalex, daratumumab (J9145) (medical)

  • Darzalex Faspro, daratumumab/hyaluronidase-fihj (J9144) (medical)

  • Daurismo (glasdegib)

  • Doxil, doxorubicin liposomal (Q2050) (medical)

  • Elahere, mirvetuximab soravtansine-gynx (J9063) (medical)

  • Eligard, leuprolide (J9217) (medical)

  • Ellence, epirubicin (J9178) (medical)

  • Elrexfio, elranatamab-bcmm (J1323) (medical)

  • Elzonris, tagraxofusp-erzs (J9269) (medical)

  • Emcyt (estramustine)

  • Empliciti, elotuzumab (J9176) (medical)

  • Enhertu, fam-trastuzumab deruxtecan-nxki (J9358) (medical)

  • Epkinly, epcoritamab-bysp (J9321) (medical)

  • Erbitux, cetuximab (J9055)  (medical)

  • Erivedge (vismodegib)

  • Erleada (apalutamide)

  • Erwinaze, asparaginase (J9019) (medical)

  • Evomela, melphalan (J9246) (medical)

  • Exkivity (mobocertinib)

  • Fareston (toremifene)

  • Faslodex, fulvestrant (J9393, J9394, J9395) (medical)

  • Fensolvi, leuprolide (J1951) (medical)

  • Firmagon, degarelix (J9155) (medical)

  • floxuridine (J9200) (medical)

  • Folotyn, pralatrexate (J9307) (medical)

  • Fotivda (tivozanib)**

  • Fruzaqla (fruquintinib)

  • Fyarro, sirolimus (J9331) (medical)

  • Gavreto (pralsetinib)

  • Gazyva, obinutuzumab (J9301) (medical)

  • Gilotrif (afatinib)

  • Gleevec (imatinib)

  • Gliadel (carmustine) (medical)

  • Halaven, eribulin (J9179) (medical)

  • Hepzato, melphalan (medical)

  • Herceptin, trastuzumab (J9355) (medical)

  • Herceptin Hylecta, trastuzumab/ hyaluronidase-oysk (J9356) (medical)

  • Herzuma, trastuzumab-pkrb (Q5113) (medical)

  • Hycamtin (topotecan)

  • Ibrance (palbociclib)

  • Iclusig (ponatinib)

  • Idhifa (enasidenib)

  • Imbruvica (ibrutinib)

  • Imdelltra, tarlatamab-dlle  (medical)

  • Imfinzi, durvalumab (J9173)  (medical)

  • Imjudo, tremelimumab-actl (J9347) (medical)

  • Imlygic, talimogene laherparepvec (J9325) (medical)

  • Inlyta (axitinib)

  • Inqovi  (decitabine/ cedazuridine)

  • Inrebic (fedratinib)

  • Iressa (gefitinib)

  • Istodax, romidepsin (J9318, J9319) (medical)

  • Iwilfin (eflornithine)

  • Ixempra, ixabepilone (J9207) (medical)

  • Jakafi (ruxolitinib)

  • Jaypirca (pirtobrutinib)

  • Jelmyto, mitomycin (J9281) (medical)

  • Jemperli, dostarlimab-gxly (J9272) (medical)

  • Jesduvroq (daprodustat)

  • Jevtana, cabazitaxel (J9043, J9064) (medical)

  • Kadcyla, ado-trastuzumab emtansine (J9354) (medical)

  • Kanjinti, trastuzumab-anns (Q5117) (medical)

  • Keytruda, pembrolizumab (J9271) (medical)

  • Kimmtrak, tebentafusp-tebn (J9274) (medical)

  • Kisqali (ribociclib)

  • Kisqali Femara (ribociclib/ letrozole)

  • Koselugo (selumetinib)

  • Krazati (adagrasib)

  • Kymriah, tisagenlecleucel (Q2042) (medical)

  • Kyprolis, carfilzomib (J9047) (medical)

  • Lemtrada, alemtuzumab (J0202) (medical)

  • Lenvima (lenvatinib)

  • leuprolide non-depot

  • Libtayo, cemiplimab-rwlc (J9119) (medical)

  • Lipodox, doxorubicin liposomal (Q2049) (medical)

  • Lonsurf (trifluridine/ tipiracil)

  • Loqtorzi, toripalimab-tpzi (J3263) (medical)

  • Lorbrena (lorlatinib)

  • Lumakras (sotorasib)

  • Lumoxiti, moxetumomab pasudotox-tdfk (J9313) (medical)

  • Lunsumio, mosunetuzumab-axgb (J9350) (medical)

  • Lupron Depot, leuprolide (J1950, J1954, J9217) (medical)

  • Lynparza (olaparib)

  • Lytgobi (futibatinib)

  • Margenza, margetuximab-cmkb (J9353)**(medical)

  • Matulane  (procarbazine)

  • Mavenclad (cladribine)

  • Mekinist (trametinib)

  • Mektovi (binimetinib)

  • mitoxantrone (J9293) (medical)

  • Monjuvi, tafasitamab-cxix  (J9349) (medical)

  • Mvasi, bevacizumab-awwb (  Q5107) (medical)

  • Mylotarg, gemtuzumab ozogamicin (J9203) (medical)

  • Navelbine, vinorelbine (J9390) (medical)

  • Nerlynx (neratinib)

  • Nexavar (sorafenib)

  • Nilandron (nilutamide)

  • Ninlaro (ixazomib)

  • Nipent, pentostatin (J9268) (medical)

  • Nubeqa (darolutamide)

  • Odomzo (sonidegib)

  • Ogivri, trastuzumab-dkst (Q5114) (medical)

  • Ogsiveo (nirogacestat)

  • Ojemda, tovorafenib

  • Ojjaara (momelotinib)

  • Oncaspar, pegaspargase (J9266) (medical)

  • Onivyde, irinotecan liposome (J9205) (medical)

  • Ontruzant, trastuzumab-dttb (Q5112) (medical)

  • Onureg (azacitidine)

  • Opdivo, nivolumab (J9299) (medical)

  • Opdualag, nivolumab/ relatlimab-rmbw (J9298) (medical)

  • Orgovyx (relugolix)

  • Orserdu (elacestrant)

  • Padcev, enfortumab vedotin-ejfv (J9177) (medical)

  • Pemazyre (pemigatinib)

  • Pemfexy, pemetrexed (J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324) (medical)

  • Pemrydi RTU, pemetrexed (J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324) (medical)

  • Perjeta, pertuzumab (J9306) (medical)

  • Phesgo, pertuzumab/ trastuzumab/ hyaluronidase-zzxf (J9316) (medical)

  • Photofrin, porfimer (J9600) (medical)

  • Piqray (alpelisib)

  • Polivy, Polatuzumab vedotin-piiq (J9309) (medical)

  • Pomalyst (pomalidomide)

  • Portrazza, necitumumab (J9295) (medical)

  • Poteligeo, mogamulizumab-kpkc (J9204) (medical)

  • Proleukin, aldesleukin (J9015) (medical)

  • Provenge, sipuleucel-T (Q2043) (medical)

  • Qinlock (ripretinib)

  • Retevmo (selpercatinib)

  • Revlimid (lenalidomide)

  • Rezlidhia (olutasidenib)

  • Riabni, rituximab-arrx (Q5123) (medical)

  • Rituxan, rituximab (J9312) (medical)

  • Rituxan Hycela, rituximab/ hyaluronidase (J9311) (medical)

  • Rozlytrek (entrectinib)

  • Rubraca (rucaparib)

  • Ruxience, rituximab-pvvr (Q5119) (medical)

  • Rybrevant, amivantamab-vmjw (J9061) (medical)

  • Rydapt (midostaurin)

  • Rylaze, asparaginase (J9021) (medical)

  • Sandostatin LAR, octreotide (J2353)  (medical)

  • Sarclisa, isatuximab-irfc (J9227) (medical)

  • Scemblix (asciminib)

  • Sprycel (dasatinib)

  • Stivarga (regorafenib)

  • Sutent (sunitinib)

  • Synribo, omacetaxine (J9262) (medical)

  • Tabloid (thioguanine)

  • Tabrecta (capmatinib)

  • Tafinlar (dabrafenib)

  • Tagrisso (osimertinib)

  • Talvey, talquetamab-tgvs (J3055) (medical)

  • Talzenna (talazoparib)

  • Tarceva (erlotinib)

  • Targretin (bexarotene)

  • Tasigna (nilotinib)

  • Tazverik (tazemetostat)

  • Tecartus, brexucabtagene autoleucel (Q2053) (medical)

  • Tecentriq, atezolizumab (J9022) (medical)

  • Tecvayli, teclistamab-cqyv (J9380) (medical)

  • Temodar (temozolomide)

  • Temodar IV, temozolomide (J9328) (medical)

  • Tepadina, thiotepa  (J9340) (medical)

  • Tepmetko (tepotinib)

  • Thalomid (thalidomide)

  • Tibsovo (ivosidenib)

  • Tice BCG, Bacillus of Calmette and Guerin vaccine, live (J9030) (medical)

  • Tivdak, tisotumab vedotin-tftv (J9273) (medical)

  • Torisel, temsirolimus (J9330) (medical)

  • Trazimera, trastuzumab-qyyp (Q5116) (medical)

  • Treanda, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059) (medical)

  • Trelstar, triptorelin (J3315) (medical)

  • Trodelvy, sacituzumab govitecan-hziy (J9317) (medical)

  • Truqap (capivasertib)

  • Truxima, rituximab-abbs (Q5115) (medical)

  • Tukysa (tucatinib)

  • Turalio (pexidartinib)

  • Tykerb (lapatinib)

  • Unituxin (dinutuximab) (medical)

  • Valstar, valrubicin  (J9357) (medical)

  • Vanflyta (quizartinib)

  • Vectibix, panitumumab (J9303) (medical)

  • Vegzelma, bevacizumab-adcd (Q5129) (medical)

  • Velcade, bortezomib (J9041, J9046, J9048, J9049, J9051) (medical)

  • Venclexta (venetoclax)

  • Verzenio (abemaciclib)

  • Vijoice (alpelisib)

  • Vitrakvi (larotrectinib)

  • Vivimusta, bendamustine (J9033, J3034, J9036, J9056, J9058, J9059) (medical)

  • Vizimpro (dacomitinib)

  • Vonjo (pacritinib)

  • Votrient (pazopanib)

  • Vyxeos, daunorubicin/ cytarabine, liposome (J9153) (medical)

  • Welireg (belzutifan)

  • Xalkori (crizotinib)

  • Xospata (gilteritinib)

  • Xpovio (selinexor)

  • Xtandi (enzalutamide)

  • Yervoy, ipilimumab (J9228) (medical)

  • Yescarta, axicabtagene ciloleucel (Q2041) (medical)

  • Yondelis, trabectedin (J9352) (medical)

  • Yonsa (abiraterone)

  • Zaltrap, ziv-aflibercept (J9400) (medical)

  • Zanosar, streptozocin (J9320) (medical)

  • Zejula (niraparib)

  • Zelboraf (vemurafenib)

  • Zepzelca, lurbinectedin (J9223) (medical)

  • Zirabev, bevacizumab-bvzr (Q5118) (medical)

  • Zoladex, goserelin (J9202) (medical)

  • Zolinza (vorinostat)

  • Zydelig (idelalisib)

  • Zykadia (ceritinib)

  • Zytiga (abiraterone)

  • Zynlonta, loncastuximab tesirine-lpyl (J9359) (medical)

  • Zynyz, retifanlimab-dlwr (J9345) (medical)

**Drug is not covered

Reviewed by LJS/BNN 7/18/24

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