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)

  • Abirtega (abiraterone)

  • Actimmune (interferon gamma-1b)

  • 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 (J9028) (medical)

  • Arranon, nelarabine (J9261) (medical)

  • Arzerra, ofatumumab (J9302) (medical)

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

  • Aucatzyl, obecabtagene autoleucel (Q2058) (medical)

  • Augtyro (repotrectinib)

  • Avastin, bevacizumab (J9035) (medical)

  • Avmapki Fakzynja (avutometinib/ defactinib)

  • Ayvakit (avapritinib)

  • Balversa (erdafitinib)

  • Bavencio, avelumab (J9023) (medical)

  • Beizray, docetaxel (J9174) (medical)

  • Beleodaq, belinostat (J9032) (medical)

  • Belrapzo, bendamustine (J9033, J9034, J9036, J9056) (medical)

  • Bendeka, bendamustine (J9033, J9034, J9036, J9056)  (medical)

  • Besponsa, inotuzumab ozogamicin (J9229) (medical)

  • Besremi (ropeginterferon alfa-2b-njft)

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

  • Bizengri, zenocutuzumab-zbco (J9382) (medical)

  • Blenrep, belantamab mafodotin-blmf (medical)

  • Blincyto, blinatumomab (J9039) (medical)

  • Boruzu, bortezomib (J9054) (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)

  • Datroway, datopotamab deruxtecan-dlnk (J9011) (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)

  • Emrelis, telisotuzumab vedotin-tllv (C9306) (medical)

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

  • Ensacove (ensartinib)

  • 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 (J9050) (medical)

  • Gomekli (mirdametinib)

  • Halaven, eribulin (J9179) (medical)

  • Hepzato, melphalan (J9248) (medical)

  • Herceptin, trastuzumab (J9355) (medical)

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

  • Hercessi, trastuzumab-strf (Q5146) (medical)
  • Hernexeos (zongertinib)
  • Herzuma, trastuzumab-pkrb (Q5113) (medical)

  • Hycamtin (topotecan)

  • Hyrnuo (sevabertinib)

  • Ibrance (palbociclib)

  • Ibtrozi (taletrectinib)

  • Iclusig (ponatinib)

  • Idhifa (enasidenib)

  • Imbruvica (ibrutinib)

  • Imdelltra, tarlatamab-dlle (J9026) (medical)

  • Imfinzi, durvalumab (J9173)  (medical)

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

  • Imlygic, talimogene laherparepvec (J9325) (medical)

  • Inlexzo, gemcitabine (medical)

  • Inluriyo (imlunestrant)

  • Inlyta (axitinib)

  • Inqovi  (decitabine/ cedazuridine)

  • Inrebic (fedratinib)

  • Iressa (gefitinib)

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

  • Itovebi (inavolisib) 
  • Ivra, melphalan (J9249) (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)

  • Jobevne, bevacizumab-nwgd (medical)

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

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

  • Keytruda, pembrolizumab (J9271) (medical)

  • Keytruda Qlex, pembrolizumab/ berahyaluronidase

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

  • Kisqali (ribociclib)

  • Kisqali Femara (ribociclib/ letrozole)

  • Komzifti (ziftomenib)

  • Koselugo (selumetinib)

  • Krazati (adagrasib)

  • Kymriah, tisagenlecleucel (Q2042) (medical)

  • Kyprolis, carfilzomib (J9047) (medical)

  • Lazcluze (lazertinib)

  • 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)

  • Lymphir, denileukin diftitox-cxdl (J9161) (medical)
  • Lynozyfic, linvoseltamab-gcpt (medical)
  • Lynparza (olaparib)

  • Lytgobi (futibatinib)

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

  • Matulane  (procarbazine)

  • Mavenclad (cladribine)

  • Mekinist (trametinib)

  • Mektovi (binimetinib)

  • mitoxantrone (J9293) (medical)

  • Modeyso (dordaviprone)

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

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

  • Mylotarg, gemtuzumab ozogamicin (J9203) (medical)

  • Navelbine, vinorelbine (J9390) (medical)

  • Nerlynx (neratinib)

  • Nexavar (sorafenib)

  • Niktimvo (axatilimab-csfr) (J9038) (medical)

  • 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)

  • Opdivo Qvantig, nivolumab/ hyaluronidase-nvhy (J9289) (medical)

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

  • Orgovyx (relugolix)

  • Orserdu (elacestrant)

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

  • Papzimeos, zopapogene imadenovec-drba (medical)

  • Pemazyre (pemigatinib)

  • Pemfexy, pemetrexed (J9292, J9294, J9296, J9297, J9304, J9305, J9314, J9322, J9323, J9324) (medical)

  • Pemrydi RTU, pemetrexed (J9292, 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)

  • Revuforj (revumenib)

  • Rezlidhia (olutasidenib)

  • Rezurock (belumosudil)

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

  • Rituxan, rituximab (J9312) (medical)

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

  • Romvimza (vimseltinib)

  • Rozlytrek (entrectinib)

  • Rubraca (rucaparib)

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

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

  • Rydapt (midostaurin)

  • Rylaze, asparaginase (J9021) (medical)

  • Ryoncil, remestemcel-L-rknd (J3402) (medical)

  • Rytelo, imetelstat (J0870) (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)

  • Targretin gel (bexarotene)

  • Tasigna (nilotinib)

  • Tazverik (tazemetostat)

  • Tecartus, brexucabtagene autoleucel (Q2053) (medical)

  • Tecelra, afamitresgene autoleucel (Q2057) (medical)

  • Tecentriq, atezolizumab (J9022) (medical)

  • Tecentriq Hybreza, atezolizumab/ hyaluronidase-tqjs (J9024) (medical)

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

  • Temodar (temozolomide)

  • Temodar IV, temozolomide (J9328) (medical)

  • Tepadina, thiotepa  (J9342) (medical)

  • Tepmetko (tepotinib)

  • Tepylute, thiotepa (J9341) (medical)

  • Tevimbra, tislelizumab-jsgr (J9329) (medical)

  • 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)

  • Unloxcyt, cosibelimab-ipdl (J9275) (medical)

  • Vabrinty, leuprolide (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)

  • Voranigo (vorasidenib)

  • Votrient (pazopanib)

  • Vyloy, zolbetuximab-clzb (J1326) (medical)

  • 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)

  • Ziihera, zanidatamab-hrii (J9276) (medical)

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

  • Zoladex, goserelin (J9202) (medical)

  • Zolinza (vorinostat)

  • Zusduri, mitomycin (medical) 

  • Zydelig (idelalisib)

  • Zykadia (ceritinib)

  • Zytiga (abiraterone)

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

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

**Drug is not covered

Reviewed by LJS 12/11/25