Oncologic Therapies
Afinitor®
Alecensa
Alunbrig
Arzerra
Bavencio
Besponsa
Bosulif
Braftovi™
Cotellic®
Cyramza
Gazyva
Gilotrif
Erleada™
Erivedge®
Halaven®
Ibrance®
Imbruvica
Imfinzi®
Imlygic®
Ixempra®
Jevtana®
Kadcyla®
Keytruda®
Kymriah™
Kisqali®
Libtayo®
Lynparza®
Mekinist®
Mektovi®
Nerlynx™
Opdivo®
Perjeta®
Provenge®
Tafinlar®
Tagrisso
Tarceva
Tecentriq
Tykerb®
Venclexta
Verzenio™
Xalkori
Xofigo®
Xtandi®
Yervoy®
Yescarta®
Yonsa®
Zelboraf®
Zydelig
Zykadia
Zytiga®
everolimus (Afinitor®) *Pharmacy billing only |
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Afinitor® (Everolimus) Approval Criteria (Breast Cancer Diagnosis):
Afinitor® (Everolimus) Approval Criteria [Neuroendocrine Tumors of Pancreatic Origin (PNET) or Neuroendocirne Tumors (NET) of Gastrointestinal or Lung OriginDiagnosis]:
Afinitor® (Everolimus) Approval Criteria (Renal Cell Carcinoma Diagnosis):
Afinitor® (Everolimus) Approval Criteria [Renal Angiomyolipoma and Tuberous Sclerosis Complex (TSC) Diagnosis]:
Afinitor® (Everolimus) Approval Criteria [Subependymal Giant Cell Astrocytoma (SEGA) with Tuberous Sclerosis Complex (TSC) Diagnosis]:
Afinitor® (Everolimus) Approval Criteria [Tuberous Sclerosis Complex (TSC)-Associated Partial-Onset Seizures Diagnosis]:
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alectinib(Alecensa®) |
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Alecensa® (Alectinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
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brigatinib (Alunbrig™) |
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Alunbrig™ (brigatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
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ofatumumab (Arzerra®) |
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Arzerra® (Ofatumumab) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:
Arzerra® (Ofatumumab) Approval Criteria [Waldenström’s Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma Diagnosis]:
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avelumab (Bavencio®) |
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Bavencio® (Avelumab) Approval Criteria [Merkel Cell Carcinoma (MCC) Diagnosis]:
Bavencio® (Avelumab) Approval Criteria [Urothelial Carcinoma Diagnosis]:
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inotuzumab ozogamicin (Besponsa®) |
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Besponsa® (Inotuzumab Ozogamicin) Approval Criteria:
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bosutinib (Bosulif®) |
bosutinib (Bosulif®) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:
bosutinib (Bosulif®) Approval Criteria [Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia (ALL) Diagnosis]:
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encorafenib (Braftovi™) |
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Braftovi™ (Encorafenib) Approval Criteria [Melanoma Diagnosis]:
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cobimetinib (Cotellic®) |
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Cotellic® (Cobimetinib) Approval Criteria [Melanoma Diagnosis]:
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ramucirumab (Cyramza®) |
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Cyramza® (Ramucirumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Cyramza® (Ramucirumab) Approval Criteria [Colorectal Cancer Diagnosis]:
Cyramza® (Ramucirumab) Approval Criteria [Esophageal Cancer Diagnosis]:
Cyramza® (Ramucirumab) Approval Criteria [Gastric Cancer Diagnosis]:
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vismodegib (Erivedge®) |
Erivedge® (Vismodegib) Approval Criteria [Basal Cell Carcinoma Diagnosis]:
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apalutamide (Erleada™) |
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apalutamide (Erleada™) Interim Approval Criteria:
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obinutuzumab (Gazyva®) |
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Gazyva® (Obinutuzumab) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:
Gazyva® (Obinutuzumab) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:
Gazyva® (Obinutuzumab) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:
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afatinib(Gilotrif®) |
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Gilotrif® (Afatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]: The following criteria must be met when used in the first-line setting:
The following criteria must be met when used in the second-line setting:
Gilotrif® (Afatinib) Approval Criteria [Head and Neck Cancer Diagnosis]:
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eribulin (Halaven®) |
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Halaven® (Eribulin) Approval Criteria (Medical Billing Only):
Halaven® (Eribulin) Approval Criteria [Liposarcoma Diagnosis]:
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palbociclib (Ibrance®) |
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Ibrance® (Palbociclib)* Approval Criteria (Pharmacy Billing Only):
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ibrutinib (Imbruvica®) |
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Imbruvica® (Ibrutinib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Chronic Graft-Versus-Host Disease (cGVHD) Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Histologic Transformation of Marginal Zone Lymphoma (MZL) to Diffuse Large B-Cell Lymphoma Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Diffuse Large B-Cell Lymphoma Diagnosis or Acquired Immunodeficiency Syndrome (AIDS)-Related B-Cell Lymphoma Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Post-Transplant Lymphoproliferative Disorders Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Hairy Cell Leukemia Diagnosis]:
Imbruvica® (Ibrutinib) Approval Criteria [Waldenström’s Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma Diagnosis]:
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durvalumab (Imfinzi®) |
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Imfinzi® (Durvalumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Imfinzi® (Durvalumab) Approval Criteria [Urothelial Carcinoma Diagnosis]:
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talimogene laherparepvec (Imlygic®) |
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Imlygic® (Talimogene Laherparepvec) Approval Criteria [Melanoma Diagnosis]: All of the following criteria must be met for approval:
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ixabepilone (Ixempra®) |
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Ixempra® (Ixabepilone) Approval Criteria (Medical Billing Only):
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cabazitaxel (Jevtana®) |
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Jevtana® (Cabazitaxel) Approval Criteria (Medical Billing Only):
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ado-trastuzumab (Kadcyla®) |
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Kadcyla® (Ado-Trastuzumab) Approval Criteria (Medical Billing Only):
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pembrolizumab (Keytruda®) |
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Keytruda® (Pembrolizumab) Approval Criteria [Cervical Cancer Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Hodgkin Lymphoma Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Head and Neck Cancer Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Melanoma Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Microsatellite Instability-High (MSI-H) or Mismatch Repair Deficient (dMMR) Solid Tumor (Tissue/Site-Agnostic) or Metastatic Colorectal Cancer Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Primary Mediastinal Large B-cell Lymphoma (PMBCL) Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Urothelial Carcinoma Diagnosis]:
Keytruda® (Pembrolizumab) Approval Criteria [Gastric or Gastroesophageal Junction Tumor Diagnosis]:
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ribociclib (Kisqali®) |
Kisqali® (Ribociclib) Approval Criteria [Breast Cancer Diagnosis]:
Kisqali® Femara® Co-Pack (Ribociclib/Letrozole) Approval Criteria:
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tisagenlecleucel (Kymria™) |
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tisagenlecleucel (Kymriah™) Approval Criteria [Lymphoma Diagnosis]:
tisagenlecleucel (Kymriah™) Approval Criteria [Acute Lymphoblastic Leukemia (ALL) Diagnosis]:
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cemiplimab-rwlc (Libtayo®) |
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Libtayo® (Cemiplimab-rwlc) Approval Criteria [Cutaneous Squamous Cell Carcinoma (CSCC) Diagnosis]:
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olaparib (Lynparza®) |
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Lynparza® (Olaparib) Approval Criteria [Ovarian Cancer Diagnosis]:
Lynparza® (Olaparib) Approval Criteria [Breast Cancer Diagnosis]:
Lynparza® (Olaparib) Approval Criteria [Maintenance Treatment Diagnosis]:
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trametinib (Mekinist®) |
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Mekinist® (Trametinib) Approval Criteria [Anaplastic Thyroid Cancer (ATC) Diagnosis]:
Mekinist® (Trametinib) Approval Criteria [Melanoma Diagnosis]:
Mekinist® (Trametinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
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binimetinib (Mektovi®) |
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Mektovi® (Binimetinib) Approval Criteria [Melanoma Diagnosis]:
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neratinib (Nerlynx™) |
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Nerlynx™ (Neratinib) Approval Criteria:
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nivolumab(Opdivo®) |
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Opdivo® (Nivolumab) Approval Criteria [Adjuvant Treatment of Melanoma]:
Opdivo® (Nivolumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Small Cell Lung Cancer Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Hodgkin Lymphoma Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Head and Neck Cancer]:
Opdivo® (Nivolumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Metastatic Colorectal Cancer Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Microsatellite Instability-High (MSI-H) or Mismatch Repair Deficient (dMMR) Metastatic Colorectal Cancer Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Renal Cell Carcinoma(RCC) Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Unresectable of Metastatic Melanoma Diagnosis]:
Opdivo® (Nivolumab) Approval Criteria [Urothelial Bladder Cancer Diagnosis]:
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pertuzumab (Perjeta®) |
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Perjeta® (Pertuzumab) Approval Criteria (Medical Billing Only):
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sipuleucel-T (Provenge®) |
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Provenge® (Sipuleucel-T) Approval Criteria (Medical Billing Only):
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dabrafenib (Tafinlar®) |
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Tafinlar® (Dabrafenib) Approval Criteria [Anaplastic Thyroid Cancer (ATC) Diagnosis]:
Tafinlar® (Dabrafenib) Approval Criteria [Melanoma Diagnosis]:
Tafinlar® (Dabrafenib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
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osimertinib (Tagrisso™) |
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Tagrisso™ (Osimertinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
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erlotinib (Tarceva®) |
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Tarceva® (Erlotinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Tarceva® (Erlotinib) Approval Criteria [Pancreatic Cancer Diagnosis]:
Tarceva® (Erlotinib) Approval Criteria [Kidney Cancer Diagnosis]:
Tarceva® (Erlotinib) Approval Criteria [Bone Cancer – Chordoma Diagnosis]:
Tarceva® (Erlotinib) Approval Criteria [Pancreatic Adenocarcinoma Diagnosis]:
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atezolizumab (Tecentriq®) |
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Tecentriq® (Atezolizumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Tecentriq® (Atezolizumab) Approval Criteria [Urothelial Carcinoma]:
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lapatinib (Tykerb®) |
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Tykerb® (Lapatinib) Approval Criteria (Pharmacy Billing Only):
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venetoclax (Venclexta®) |
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Venclexta™ (Venetoclax) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:
Venclexta™ (Venetoclax) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:
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abemaciclib (Verzenio™) |
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Verzenio™ (Abemaciclib) Approval Criteria [Breast Cancer Diagnosis]:
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radium-223 dicloride (Xofigo®) |
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Xofigo® (Radium-223 Dichloride) Approval Criteria (Pharmacy Billing Only):
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crizotinib (Xalkori®) |
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Xalkori® (Crizotinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Xalkori® (Crizotinib) Approval Criteria [Soft Tissue Sarcoma – Inflammatory Myofibroblastic Tumor (IMT) with Anaplastic Lymphoma Kinase (ALK) Translocation Diagnosis]:
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enzalutamide (Xtandi®) |
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Xtandi® (Enzalutamide) Approval Criteria (Pharmacy Billing Only):
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abiraterone (Yonsa®) |
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Yonsa® (Abiraterone) Approval Criteria:
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ipilimumab (Yervoy®) |
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Yervoy® (Ipilimumab) Approval Criteria [Adjuvant Treatment of Melanoma]:
Yervoy® (Ipilimumab) Approval Criteria [Metastatic Colorectal Cancer Diagnosis]:
Yervoy® (Ipilimumab) Approval Criteria [Renal Cell Carcinoma (RCC) Diagnosis]:
Yervoy® (Ipilimumab) Approval Criteria [Small Cell Lung Cancer Diagnosis]:
Yervoy® (Ipilimumab) Approval Criteria [Unresectable or Metastatic Melanoma Diagnosis]:
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axicabtagene (Yescarta®) |
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Yescarta® (Axicabtagene) Approval Criteria [Lymphoma Diagnosis]:
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abiraterone (Yonsa®) |
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Yonsa® (Abiraterone) Approval Criteria:
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vemurafenib (Zelboraf®) |
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Zelboraf® (Vemurafenib) Approval Criteria [Melanoma Diagnosis]:
Zelboraf® (Vemurafenib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Zelboraf® (Vemurafenib) Approval Criteria [Hairy-Cell Leukemia Diagnosis]:
Zelboraf® (Vemurafenib) Approval Criteria [Erdheim-Chester Disease]:
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idelalisib (Zydelig®) |
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Zydelig® (Idelalisib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:
Zydelig® (Idelalisib) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:
Zydelig® (Idelalisib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:
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ceritinib (Zykadia®) |
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Zykadia® (Ceritinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:
Zykadia® (Ceritinib) Approval Criteria [Soft Tissue Sarcoma – Inflammatory Myofibroblastic Tumor (IMT) with Anaplastic Lymphoma Kinase (ALK) Translocation Diagnosis]:
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abiraterone (Zytiga®) - Pharmacy Billing Only |
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Zytiga® (abiraterone) Approval Criteria [Castration-Sensitive Prostate Cancer (CSPC) Diagnosis]:
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