(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Ovulatory Stimulants (Follitropins)
FOLLISTIM AQ
GONAL-F, GONAL-F RFF REDI-JECT
Prenatal Vitamins
CITRANATAL, NATAL PNV, PREGENNA, TRINAZ generic prenatal vitamins
Topical Estrogen Agents Vaginal Progesterones
ELESTRIN
estradiol gel, gel pump or patches
CRINONE 4%
medroxyprogesterone, megestrol, norethindrone, progesterone
Miscellaneous Gynecological Agents ONCOLOGY Acute Myeloid Leukemia (AML) Agents
paroxetine mesylate
paroxetine hcl, paroxetine hcl er
ONUREG
Coverage may be approved for the treatment of Acute Myeloid Leukemia under certain conditions.
REZLIDHIA VANFLYTA GRAFAPEX COLUMVI
TIBSOVO RYDAPT
Alkylating Agents
busulfan, cyclophosphamide, etoposide, fludarabine Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions. Coverage may be approved for the treatment of Follicular Lymphoma or Diffuse Large B-cell Lymphoma under certain conditions.
B-Cell Lymphoma Agents
EPKINLY, LUNSUMIO VELO
Bendamustine Agents
VIVIMUSTA
bendamustine, BENDEKA
Bevacizumab-Containing Agents
ALYMSYS, AVASTIN, JOBEVNE, VEGZELMA
ZIRABEV
Bispecific Human Epidermal Growth Factor Receptor 2 (HER2)-Directed Antibody
ZIIHERA
PERJETA plus HERCESSI or OGIVRI
Bortezomib Agents
BORUZU
bortezomib
Bruton Tyrosine Kinase Inhibitors
BRUKINSA, JAYPIRCA
For Mantle Cell Lymphoma: CALQUENCE For Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma: CALQUENCE, IMBRUVICA For BRUKINSA only: Coverage may be approved for treatment of Waldenström’s Macroglobulinemia under certain conditions. acitretin, bexarotene capsules, isotretinoin, romidepsin, ADCETRIS, POTELIGEO, ZOLINZA
Cutaneous T-Cell Lymphoma Agents
LYMPHIR
Docetaxel Agents
BEIZRAY/ALBUMIN, DOCIVYX
docetaxel fluorouracil gemcitabine
Fluorouracil Injectable Products
FAVLYXA AVGEMSI LIFYORLI
Gemcitabine Agents
Glucocorticoid Receptor Antagonists
Coverage may be approved for the treatment of Platinum Resistant Epithelial Ovarian, Fallopian Tube or Primary Peritoneal Cancer under certain conditions.
Interferons
BESREMI INLEXZO ITOVEBI
hydroxyurea
Intravesical Agents Kinase Inhibitors
gemcitabine, mitomycin, valrubicin
Coverage may be approved for the treatment of Breast Cancer under certain conditions.
Leucovorin Agents
VYKOURA
leucovorin injection melphalan injection
Melphalan Injectable Agents Multiple Myeloma Agents
IVRA
BLENREP, XPOVIO
bortezomib, lenalidomide, pomalidomide, DARZALEX, KYPROLIS, NINLARO, THALOMID
Myelodysplastic Syndrome Agents
INQOVI
decitabine
Myelofibrosis Agents
INREBIC, OJJAARA
JAKAFI, JAKAFI XR
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