(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Non-Small Cell Lung Cancer Agents
HERNEXEOS, HYRNUO
Coverage may be approved for the treatment of HER2 (ERBB2) activating mutation non-small cell lung cancer. Coverage may be approved for the treatment of KRAS G12C-mutated non-small cell lung cancer.
KRAZATI
TEPMETKO
TABRECTA LYNPARZA
PARP Inhibitors
RUBRACA, ZEJULA
Pemetrexed Agents
AXTLE
pemetrexed disodium
Programmed Death Ligand-1 Blocking Antibodies
UNLOXCYT
KEYTRUDA, KEYTRUDA QLEX, LIBTAYO abiraterone plus LYNPARZA, TALZENNA plus XTANDI ELIGARD, FIRMAGON, LUPRON DEPOT, LUTRATE DEPOT
Prostate Cancer Agents
AKEEGA
CAMCEVI, LEUPROLIDE DEPOT, TRELSTAR, VABRINTY
Renal Cell Cancer Agents Rituximab-Containing Agents Thiotepa Injectable Agents Trabectedin Injectable Products Trastuzumab-Containing Agents
FOTIVDA
CABOMETYX, INLYTA, LENVIMA
RIABNI, RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE
TEPYLUTE
thiotepa
EVDI
YONDELIS
HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, KANJINTI, ONTRUZANT, TRAZIMERA
HERCESSI, OGIVRI
Tyrosine Kinase Inhibitors
PHYRAGO QINLOCK
dasanitib
imatinib, nilotinib, pazopanib, sorafenib, sunitinib, IMKELDI, STIVARGA
Tyrosine Kinase Inhibitors - Nilotinib Products
NILOTINIB TARTRATE
nilotinib hcl, DANZITEN
OPHTHALMIC Antiglaucoma Agents (Beta-Adrenergic Blockers)
BETIMOL, TIMOPTIC OCUDOSE
timolol maleate drops, betaxolol drops, carteolol drops, levobunolol drops
Antiglaucoma Agents (Ophthalmic Prostaglandins)
tafluprost drops, travoprost drops, DURYSTA, IDOSE TR, IYUZEH, OMLONTI, TRAVATAN Z, VYZULTA, ZIOPTAN, ZOLYMBUS
bimatoprost drops, latanoprost drops
Blepharoptosis Agents
UPNEEQ IZERVAY
No alternatives recommended
Ophthalmic Agents (Complement Protein C5 Inhibitors)
Coverage may be approved for the treatment of Geographic Atrophy under certain conditions.
Ophthalmic Agents (Vascular Endothelial Growth Inhibitors)
EYLEA, EYLEA HD, VABYSMO
PAVBLU CIMERLI
BYOOVIZ, LUCENTIS
SUSVIMO
No alternatives recommended
Ophthalmic Agents (Other)
ATROPINE (PRESERVATIVE FREE) 1% EYE SINGLE USE DROPPERETTE
atropine 1% drops
CYSTADROPS
CYSTARAN
VERKAZIA
azelastine drops, bepotastine drops, cromolyn drops, epinsatine drops, olopatadine drops azelastine drops, bepotastine drops, cromolyn drops, epinastine drops, olopatadine drops dexamethasone drops, difluprednate drops, fluorometholone drops, loteprednol 0.5% drops, prednisolone drops
Ophthalmic Anti-Allergic
ZERVIATE
Ophthalmic Anti-Inflammatory
BYQLOVI, CLOBETASOL DROPS, FLAREX, FML FORTE, LOTEMAX OINTMENT, LOTEMAX SM, MAXIDEX, PRED MILD
Ophthalmic Combinations
TOBRADEX ST
tobramycin/dexamethasone drops
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
ACUVAIL, ILEVRO, NEVANAC
bromfenac drops, diclofenac drops, ketorolac drops
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