Drug Class
Excluded Medications
Preferred Alternatives
Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions. For Follicular Lymphoma: LUNSUMIO
ONCOLOGY B-Cell Lymphoma Agents (continued)
EPKINLY
Bendamustine Agents
VIVIMUSTA
bendamustine, BENDEKA
Bevacizumab-Containing Agents Bispecific Human Epidermal Growth Factor Receptor 2 (HER2)-Directed Antibody
ALYMSYS, AVASTIN, VEGZELMA
ZIRABEV
ZIIHERA
PERJETA plus HERCESSI or OGIVRI
Bortezomib Agents
BORUZU
bortezomib
For Mantle Cell Lymphoma: BRUKINSA, CALQUENCE For Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma: BRUKINSA, CALQUENCE, IMBRUVICA, VENCLEXTA
Bruton Tyrosine Kinase Inhibitors JAYPIRCA
Docetaxel Agents
DOCIVYX BESREMI
docetaxel
Interferons
hydroxyurea
Coverage may be approved for the treatment of Breast Cancer under certain conditions.
Kinase Inhibitors
ITOVEBI
Melphalan Agents (Injectable)
IVRA
melphalan injection
bortezomib, DARZALEX, KYPROLIS, POMALYST, REVLIMID, THALOMID
Multiple Myeloma Agents
XPOVIO
Myelodysplastic Syndrome Agents
INQOVI
decitabine
Myelofibrosis Agents
INREBIC, OJJAARA
JAKAFI
Coverage may be approved for the treatment of KRAS G12C-mutated non-small cell lung cancer.
KRAZATI
Non-Small Cell Lung Cancer Agents
TEPMETKO
TABRECTA LYNPARZA
PARP Inhibitors
RUBRACA, ZEJULA
Pemetrexed Agents
AXTLE
pemetrexed disodium
abiraterone plus LYNPARZA, TALZENNA plus XTANDI
AKEEGA
Prostate Cancer Agents
ELIGARD, FIRMAGON, LUPRON DEPOT, LUTRATE DEPOT
CAMCEVI, LEUPROLIDE DEPOT, TRELSTAR
Renal Cell Cancer Agents Rituximab-Containing Agents Thiotepa Injectable Agents
FOTIVDA
CABOMETYX, INLYTA, LENVIMA
RIABNI, RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE
TEPYLUTE
thiotepa
HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, KANJINTI, ONTRUZANT, TRAZIMERA
Trastuzumab-Containing Agents
HERCESSI, OGIVRI
dasatinib, imatinib, nilotinib, pazopanib, sorafenib, sunitinib, IMKELDI, STIVARGA timolol drops, betaxolol drops, carteolol drops, levobunolol drops
Tyrosine Kinase Inhibitors
QINLOCK
OPHTHALMIC Antiglaucoma Agents (Beta-Adrenergic Blockers)
BETIMOL, TIMOPTIC OCUDOSE
(continued)
© 2025 Evernorth Health Services. All rights reserved. All trademarks are the property of their respective owners.
CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
Page 14
Made with FlippingBook. PDF to flipbook with ease