Jaypirca - Multiple indications
Jaypirca (pirtobrutinib) — Covered when ALL of the following are met:
The member has a documented diagnosis of relapsed or refractory mantle cell lymphoma (MCL) and has received at least two prior lines of systemic therapy, including a BTK inhibitor.
OR the member has chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) and has previously been treated with a covalent BTK inhibitor.
Prescribed by or in consultation with an oncologist.
Jubbonti (pirtobrutinib / denosumab) criteria
Jubbonti (pirtobrutinib / denosumab) — Product-specific entries:
Jubbonti (pirtobrutinib): Covered when ALL of the following are met: The member has a documented indication appropriate for pirtobrutinib per FDA labeling (e.g., relapsed/refractory MCL after prior BTK therapy) and therapy is prescribed by or in consultation with an oncologist.
Jubbonti (denosumab) — Osteoporosis: Authorized when ANY of the following are met:
--The member is at high risk of fracture.
--The member had an inadequate response to, or is unable to tolerate, at least one traditional osteoporosis treatment (examples include alendronate, ibandronate, risedronate, zoledronic acid, raloxifene).
--The member is a female at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer and denosumab is being used to increase bone mass.
Also authorized for men at high risk of fracture receiving androgen deprivation therapy for non-metastatic prostate cancer and for treatment of glucocorticoid-induced osteoporosis in patients at high fracture risk.
Jynarque (tolvaptan) criteria & monitoring
Jynarque (tolvaptan) — Initial authorization and monitoring:
Initial: Diagnosis of autosomal dominant polycystic kidney disease (ADPKD) with rapidly progressing disease.
Baseline safety: ALT, AST, and bilirubin must be measured prior to initiation.
Monitoring during first 18 months: For patients who have received Jynarque ≤ 18 months, measure ALT, AST, and bilirubin at 2 weeks and 4 weeks after initiation and then monthly for the first 18 months.
Monitoring after 18 months: For patients on therapy > 18 months, measure ALT, AST, and bilirubin at least every 3 months.
Exclusions: Patient has a history of significant liver impairment or injury (excluding uncomplicated polycystic liver disease).
Kalydeco criteria
Kalydeco (ivacaftor) — Covered when ALL of the following are met:
The member has a documented diagnosis of cystic fibrosis (CF) and has at least one CFTR mutation that is responsive to ivacaftor based on clinical and/or in vitro assay data.
If genotype is unknown, an FDA-cleared CF mutation test should be used and verification by bidirectional sequencing when recommended.
Exclusion: Not effective for patients homozygous for the F508del CFTR mutation.
Granules: patient is ≥ 1 month of age for formulations indicated for infants.
Prescriber: as clinically appropriate (e.g., pulmonologist or CF specialist).
Kerendia criteria
Kerendia (finerenone) — Covered when ALL of the following are met:
The member has a documented diagnosis of chronic kidney disease associated with type 2 diabetes, OR heart failure with left ventricular ejection fraction (LVEF) ≥ 40% when clinically indicated.
Prescriber restrictions and additional clinical context should be followed per labeling.
Kesimpta (ofatumumab) criteria
Kesimpta (ofatumumab) — Covered when ALL of the following are met:
The member has a documented diagnosis of relapsing forms of multiple sclerosis (including clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS).
The prescribing physician is a neurologist or consultant experienced in MS management.
Kineret criteria
Kineret (anakinra) — Indication-specific criteria:
Rheumatoid Arthritis (initial): Diagnosis of moderately to severely active RA AND either a trial and failure (or contraindication/intolerance) to two of the listed biologic/small-molecule therapies (examples: etanercept, adalimumab, abatacept, upadacitinib, tofacitinib) or documentation that trials are inappropriate, OR for continuation of prior therapy; prescribed by or in consultation with a rheumatologist.
NOMID (initial): Diagnosis of neonatal-onset multisystem inflammatory disease (NOMID) confirmed by NLRP3 mutation OR clinical criteria plus elevated acute phase reactants; prescribed by or in consultation with an allergist/immunologist, rheumatologist, or pediatrician.
Continuation/reauthorization: Patient demonstrates positive clinical response as documented by symptom improvement or objective measures (e.g., reduced joint counts for RA).
Krazati criteria
Krazati (adagrasib) — Covered when ALL of the following are met:
Non-small cell lung cancer (NSCLC): Documented locally advanced or metastatic NSCLC with KRAS G12C mutation and prior systemic therapy; prescribed by or in consultation with an oncologist.
Colorectal cancer (CRC): Documented KRAS G12C-mutated locally advanced or metastatic CRC with prior fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy; when used in combination with cetuximab per labeling.
Other uses consistent with FDA-approved indications and guidance.
Lenalidomide criteria
Lenalidomide — Indication-specific coverage criteria (selected examples):
Multiple myeloma: Use per labeling; prior lines of therapy and combination regimens as indicated.
Myelodysplastic syndromes (MDS): Use for transfusion-dependent anemia due to low- or intermediate-1-risk MDS associated with 5q-deletion per criteria.
Other hematologic indications: Coverage consistent with documented diagnosis, prior therapy requirements, and prescriber being a hematologist/oncologist.
Livtencity criteria
Livtencity (maribavir) — Covered when ALL of the following are met:
The member (≥35 kg) has documented post-transplant CMV infection/disease refractory to treatment (with or without genotypic resistance) with ganciclovir, valganciclovir, cidofovir, or foscarnet.
Prescribed by or in consultation with a transplant specialist, infectious disease physician, or relevant specialist.
Lonsurf criteria
Lonsurf (trifluridine/tipiracil) — Covered when ALL of the following are met:
Metastatic colorectal cancer (mCRC): Documented mCRC and prior treatment with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF biologic, and if RAS wild-type and appropriate, an anti-EGFR therapy.
Metastatic gastric or gastroesophageal junction adenocarcinoma: Documented disease and prior treatment with at least two prior lines of chemotherapy including a fluoropyrimidine and a platinum and either a taxane or irinotecan, and HER2-directed therapy if appropriate.
Prescribed by an oncologist.
Lorbrena criteria
Lorbrena (lorlatinib) — Covered when ALL of the following are met:
Documented metastatic non-small cell lung cancer (NSCLC) with ALK-positive tumors.
Prescribed by an oncologist; use consistent with prior ALK-inhibitor exposure and labeled indications.
Lybalvi criteria
Lybalvi — Covered when ALL of the following are met:
The member has a documented diagnosis of schizophrenia or Bipolar I disorder.
The prescribing physician is a psychiatrist.
Lynparza (olaparib) criteria
Lynparza (olaparib) — Covered when ALL of the following are met (indication-specific):
Breast cancer: Deleterious or suspected deleterious germline BRCA-mutated, HER2-negative metastatic breast cancer previously treated with chemotherapy in neoadjuvant, adjuvant, or metastatic setting; if HR-positive, prior endocrine therapy or intolerance/contraindication.
Also covered for high-risk early breast cancer after neoadjuvant/adjuvant chemotherapy per labeling.
Ovarian cancer: Maintenance treatment for germline/somatic BRCA-mutated advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer in complete/partial response to first-line platinum-based chemotherapy; maintenance in combination with bevacizumab when HRD-positive as specified; recurrent disease maintenance following response to platinum-based chemotherapy.
Pancreatic cancer: Germline BRCA-mutated metastatic pancreatic adenocarcinoma with no disease progression after ≥16 weeks of first-line platinum-based chemotherapy.
Prostate cancer: Deleterious or suspected deleterious germline or somatic HRR gene-mutated mCRPC after progression on prior therapies, or BRCAm mCRPC in combination with abiraterone and prednisone/prednisolone where indicated.
Lytgobi - FGFR2 fusion positive cholangiocarcinoma
Lytgobi — Covered when ALL of the following are met:
The member has previously treated, unresectable, locally advanced or metastatic intrahepatic cholangiocarcinoma harboring FGFR2 gene fusions or other rearrangements.
Prescribed by or in consultation with an oncologist.
PAH and CTEPH – diagnostic confirmation required for pulmonary hypertension agents
PAH and CTEPH agents — Diagnostic confirmation required:
Pulmonary arterial hypertension (PAH): Diagnosis must be confirmed by right heart catheterization prior to coverage.
Chronic thromboembolic pulmonary hypertension (CTEPH): Diagnosis of persistent/recurrent CTEPH after surgical treatment or inoperable disease; diagnostic workup documented and prescribed by/with a cardiologist or pulmonologist.
Mekinist – BRAF mutation-driven indications and prior therapy considerations
Mekinist (trametinib) — Covered when ALL of the following are met:
BRAF mutation-driven indications: Member has unresectable or metastatic melanoma with BRAF V600E or V600K mutation when used as single agent per labeling OR in combination with dabrafenib (Tafinlar) for specified indications (e.g., melanoma, NSCLC with BRAF V600E, anaplastic thyroid cancer with BRAF V600E, certain solid tumors with BRAF V600E, low-grade glioma requiring systemic therapy).
Prior therapy considerations: Mekinist will not be approved as a single agent for members who have received prior BRAF-inhibitor therapy (coverage requires combination therapy where indicated).
Prescribed by an oncologist.
Otezla – Psoriasis and Psoriatic Arthritis criteria
Otezla (apremilast) — Covered when ALL of the following are met:
Psoriatic Arthritis (PsA): Documented diagnosis of psoriatic arthritis.
Plaque psoriasis (PsO): Documented moderate-to-severe plaque psoriasis and failed or unable to tolerate at least one topical or other listed therapy (examples: corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar).
Oral ulcers associated with Behcet's disease: Documented disease with active oral ulcers.
Prescribed by or in consultation with a dermatologist or rheumatologist.
Orserdu — ESR1-mutated breast cancer criteria
Orserdu (elacestrant) — Covered when ALL of the following are met:
Diagnosis of advanced or metastatic ER-positive, HER2-negative breast cancer with documented ESR1 mutation.
Disease has progressed following at least one line of endocrine therapy.
Prescribed by or in consultation with an oncologist.
Pemazyre — FGFR-altered tumors criteria
Pemazyre (pemigatinib) — Covered when ALL of the following are met:
The member has unresectable, locally advanced or metastatic cholangiocarcinoma with FGFR2 fusion or rearrangement and has been previously treated, OR has relapsed/refractory myeloid/lymphoid neoplasms with FGFR1 rearrangement as indicated.
Prescribed by an oncologist.
Piqray — PIK3CA-mutated breast cancer criteria
Piqray (alpelisib) — Covered when ALL of the following are met:
Diagnosis of HR-positive, HER2-negative, PIK3CA-mutated advanced or metastatic breast cancer.
Disease has progressed on or after an endocrine-based regimen.
Piqray is being used in combination with fulvestrant.
Prescribed by an oncologist.
Pirfenidone — IPF criteria
Pirfenidone — Covered when ALL of the following are met:
The member has a documented diagnosis of idiopathic pulmonary fibrosis (IPF).
Prescribed by or in consultation with a pulmonologist.
Pomalidomide — Kaposi sarcoma and multiple myeloma criteria
Pomalidomide (Pomalyst) — Covered when ALL of the following are met:
Kaposi sarcoma (KS): Documented diagnosis of KS after failure of highly active antiretroviral therapy (HAART) where indicated.
Multiple myeloma: Documented diagnosis and has received at least two prior therapies including lenalidomide and a proteasome inhibitor, with disease progression on or within 60 days of last therapy; used in combination with dexamethasone.
Prescribed by an oncologist.
PCSK9 inhibitors — lipid disorder criteria
PCSK9 inhibitors (e.g., Repatha, Praluent) — Lipid disorder criteria:
Member has elevated LDL-C despite high-intensity statin therapy OR has contraindication/intolerance to statins.
Member has one of: documented cardiovascular disease, primary hyperlipidemia (HeFH) confirmed by genetic testing or clinical criteria, or homozygous familial hypercholesterolemia (HoFH) confirmed by genetic testing or clinical criteria.
Prescriber documentation of baseline LDL-C and prior lipid-lowering therapy trials.
Prevymis — CMV prophylaxis criteria
Prevymis (letermovir) — CMV prophylaxis criteria: Covered when ANY of the following are met:
Member has had or is scheduled to receive an allogeneic hematopoietic stem cell transplant (HSCT) and is at risk for CMV infection.
Member has had or is scheduled to receive a kidney transplant and is at risk for CMV infection.
Prescribed per transplant infectious disease protocols.
Prolastin-c — alpha-1 antitrypsin deficiency criteria
Prolastin-C — Alpha-1 antitrypsin deficiency criteria:
Documented hereditary deficiency of alpha-1 antitrypsin with clinical evidence of emphysema.
Prescribed by or in consultation with a pulmonologist; diagnosis supported by serum AAT level and phenotype/genotype where applicable.
Qulipta — migraine criteria
Qulipta (atogepant) — Migraine criteria:
The member has a documented diagnosis of migraine.
Prescriber documents prior trials of or intolerances to standard migraine preventive therapies as appropriate.
Initial approval per labeling; reauthorization requires clinically significant reduction in monthly migraine days as documented by prescriber.
Radicava — ALS criteria
Radicava (edaravone) — ALS criteria:
The member has a documented diagnosis of amyotrophic lateral sclerosis (ALS).
Prescribed by a neurologist; use consistent with labeled indications and monitoring.
Rezdiffra — MASH/NASH criteria
Rezdiffra — MASH/NASH criteria and authorization conditions:
Initial: Diagnosis of metabolic dysfunction-associated steatohepatitis (MASH/NASH) without cirrhosis and biopsy or noninvasive testing confirming fibrosis stage F2–F3 (examples: ELF + imaging, FibroScan/FAST, MAST, MEFIB, or liver biopsy within 12 months).
Presence of ≥1 metabolic risk factor (e.g., type 2 diabetes, hypertension, obesity).
Prescribed by or in consultation with a gastroenterologist or hepatologist.
Reauthorization: Patient demonstrates positive response to therapy and has not progressed to cirrhosis; authorization durations and continuation conditions per labeling.
Rezurock — chronic GVHD criteria
Rezurock (belumosudil) — chronic GVHD criteria:
Diagnosis of chronic graft-versus-host disease (cGVHD) with trial and failure of two or more lines of systemic therapy (examples: corticosteroids, mycophenolate).
Prescribed by or in consultation with a hematologist, oncologist, or physician experienced in transplant care.
Rydapt — FLT3+ AML and mast cell diseases
Rydapt (midostaurin) — FLT3+ AML and mast cell disease indications:
Acute myeloid leukemia (AML): Documented FLT3 mutation-positive AML and Rydapt is being used as first-line therapy in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation (per labeled induction/regimen).
Mast cell disorders: Documented diagnosis of mast cell leukemia (MCL) or systemic mastocytosis (aggressive SM or SM-AHN) as indicated.
Exclusion: Rydapt will not be approved as single-agent induction therapy for AML.
Prescribed by a hematologist/oncologist or allergist where appropriate.
Rydapt indications
Rydapt indications — additional coverage notes:
Coverage aligns with specific labeled indications (AML induction in combination, mast cell disease uses) and requires mutation/diagnostic confirmation and specialist prescribing.
Not approvable as single-agent induction for AML.
Sapropterin (BH4) coverage
Sapropterin (BH4) — Coverage entry:
Documented diagnosis of hyperphenylalaninemia (HPA) due to BH4-responsive phenylketonuria (PKU).
Initial authorization 8 weeks; subsequent authorizations up to 2 years with demonstrated improvement and specialist prescribing.
Skyrizi coverage
Skyrizi (risankizumab) — Coverage entry:
Indications per labeling (e.g., plaque psoriasis, psoriatic arthritis, Crohn's disease) with documentation of prior topical or systemic therapy failures where applicable.
Prescribed by or in consultation with relevant specialists (dermatologist, rheumatologist, gastroenterologist).
Trikafta (elexacaftor/tezacaftor/ivacaftor) coverage
Trikafta (elexacaftor/tezacaftor/ivacaftor) — CF coverage:
Initial: Diagnosis of cystic fibrosis and presence of at least one CFTR mutation responsive to Trikafta (F508del or other responsive mutation per clinical/in vitro data).
Age restrictions: granule packets for ages 2–<6 years; tablets for age ≥6 years per labeling.
Prescribed by or in consultation with a pulmonologist or CF care center specialist.
Reauthorization: Patient demonstrates positive clinical response (e.g., improved ppFEV1 or fewer pulmonary exacerbations).
Tavneos (avacopan) coverage
Tavneos (avacopan) — Coverage entry:
Indications: Severe active ANCA-associated vasculitis (e.g., granulomatosis with polyangiitis or microscopic polyangiitis) in combination with standard immunosuppressive therapy as indicated by labeling.
Prescribed by or in consultation with nephrology, rheumatology, or relevant specialists.
Tibsovo (ivosidenib) coverage
Tibsovo (ivosidenib) — Coverage entry:
Indications per labeling (e.g., IDH1-mutated AML, cholangiocarcinoma) with documented mutation testing and specialist prescribing.
Coverage aligned with prior therapy/line-of-treatment requirements in labeling.
Tukysa / Turalio (mixed block)
Tukysa / Turalio (mixed oncology block) — Coverage entries:
Tukysa (tucatinib): Advanced unresectable or metastatic HER2-positive breast cancer indications (including brain metastases) per labeled combinations and prior treatment requirements; prescribed by an oncologist.
Turalio (pexidartinib): Symptomatic tenosynovial giant cell tumor (TGCT) not amenable to surgery per labeled criteria; prescribed by an oncologist or appropriate specialist.
Ubrelvy / rheumatology biologics block
Ubrelvy and selected rheumatology biologics block — Coverage entries:
Ubrelvy (ubrogepant): Acute migraine treatment for members with documented migraine and prior trial of a triptan unless contraindicated.
Rheumatology biologics (examples: Ustekinumab, Steqeyma/Yesintek): Indications per labeling for RA, psoriasis, IBD, etc., with required prior conventional therapy trials and specialist prescribing (dermatologist, rheumatologist, gastroenterologist) as specified.
Valtoco / Vanflyta / Venclexta block
Valtoco / Vanflyta / Venclexta block — Coverage entries:
Valtoco (diazepam nasal spray): Approved for acute treatment of seizure clusters with neurologist prescribing.
Vanflyta (gilteritinib alternative name coverage context): Use per labeled AML FLT3-mutated indications; specialist prescribing.
Venclexta (venetoclax): AML and CLL/ SLL and other labeled indications with line-of-therapy and combination requirements per labeling; prescribed by a hematologist/oncologist.
Voquezna / Voranigo; Voriconazole / Vosevi
Voquezna / Voranigo and related antifungal/antiviral entries:
Voquezna (vonoprazan-containing therapy) and Voranigo (example antifungal/other block) coverage per labeled indications and specialty prescribing; follow diagnosis- and prior-therapy-specific criteria where applicable (e.g., H. pylori, invasive fungal infections).
Voriconazole / Vosevi: Voriconazole for documented serious fungal infections per infectious disease guidance; Vosevi for HCV per AASLD-IDSA guidance and specialist prescribing.
Vowst / Vyndamax
Vowst / Vyndamax — Coverage entries:
Vowst (microbiota-based live biotherapeutic): Diagnosis of recurrent C. difficile infection and completion of recommended antibiotic therapy 2–4 days prior to initiation; prescribed by gastroenterologist or infectious disease specialist.
Vyndamax (tafamidis): Transthyretin-mediated amyloidosis with cardiomyopathy (ATTR-CM) initial authorization requires diagnostic confirmation (genetic mutation or biopsy/imaging) and NYHA Class I–III; prescribed by cardiologist; reauth plan-year with ongoing NYHA class I–III.
Welireg / Wyost; Wyost — authorization criteria; Denosumab — authorization criteria
Welireg / Wyost — Coverage entries and Wyost authorization criteria:
Welireg (belzutifan): Indications per labeling including von Hippel-Lindau disease–associated RCC, certain advanced RCC, and other labeled tumor types; prescribed by an oncologist.
Wyost (denosumab) — Authorized when ONE of the following is met: for prevention of skeletal-related events in patients with multiple myeloma or bone metastases from solid tumors; treatment of unresectable giant cell tumor of bone (GCTB) where surgery would cause severe morbidity; treatment of hypercalcemia of malignancy refractory to bisphosphonate therapy.
Denosumab broader authorization: Authorized when ANY of the following apply: prevention of skeletal-related events in bone-metastatic solid tumors or multiple myeloma; treatment of unresectable GCTB or where surgery would cause severe morbidity; treatment of hypercalcemia of malignancy refractory to bisphosphonates; or specific osteoporosis indications per Jubbonti denosumab criteria.
Prescriber: as clinically appropriate (oncologist, orthopedic oncology, endocrinology).
Xalkori — authorization criteria
Xalkori (crizotinib) — Authorization criteria:
Documented diagnosis of metastatic NSCLC that is ALK-positive or ROS1-positive, OR relapsed/refractory systemic ALCL that is ALK-positive, OR unresectable/refractory inflammatory myofibroblastic tumor (IMT) that is ALK-positive.
Prescribed by an oncologist; mutation testing documented.
Xdemvy — authorization criteria
Xdemvy — Authorization criteria:
Documented diagnosis of Demodex blepharitis.
Medication must be prescribed by or in consultation with an ophthalmologist or optometrist.
Xeljanz — authorization criteria
Xeljanz (tofacitinib) — Authorization criteria examples:
Indications per labeling (e.g., RA, PsA, UC, PJIA) with required prior conventional therapy trials and inadequate response or intolerance to TNF inhibitors where specified.
Prescribed by or in consultation with relevant specialists (rheumatologist, gastroenterologist).
Xermelo — authorization criteria
Xermelo (telotristat) — Authorization criteria:
Documented diagnosis of carcinoid syndrome diarrhea inadequately controlled by somatostatin analog (SSA) therapy; Xermelo used in combination with an SSA.
Prescribed by gastroenterologist or oncologist.
Xifaxan — authorization criteria
Xifaxan (rifaximin 550 mg) — Authorization criteria:
Hepatic encephalopathy: Documented diagnosis and inadequate response or contraindication to lactulose.
Irritable bowel syndrome with diarrhea (IBS-D): Documented diagnosis per clinical criteria.
Prescriber documentation required.
Xolair — authorization criteria
Xolair (omalizumab) — Authorization criteria:
Asthma: Moderate-to-severe persistent asthma with failure of a regimen including two or more controller therapies and definitive sensitivity to perennial allergens; pretreatment serum IgE between 30–1,300 IU/mL where applicable.
Chronic spontaneous urticaria: Symptomatic despite H1 antihistamines.
Nasal polyps, IgE-mediated indications per labeling; prescribed by allergist, dermatologist, immunologist, otolaryngologist, or pulmonologist.
Xospata — authorization criteria
Xospata (gilteritinib) — Authorization criteria:
Documented relapsed or refractory AML with FLT3 mutation.
Prescribed by a hematologist/oncologist.
Xpovio — authorization criteria
Xpovio (selinexor) — Authorization criteria (regimen-specific):
Combination with dexamethasone: Documented relapsed/refractory multiple myeloma after at least four prior therapies and refractory to at least two proteasome inhibitors, two immunomodulatory agents, and an anti-CD38 monoclonal antibody.
Combination with bortezomib and dexamethasone: Documented multiple myeloma with at least one prior therapy as indicated.
Relapsed/refractory DLBCL: Documented DLBCL after ≥2 lines of systemic therapy where selinexor is indicated.
Prescribed by a hematologist/oncologist.
Xtandi — authorization criteria
Xtandi (enzalutamide) — Authorization criteria:
Non-metastatic castration-resistant prostate cancer OR metastatic hormone-sensitive prostate cancer when used in combination with docetaxel per labeling.
Prescribed by an oncologist or urologist.
Steqeyma / Yesintek — authorization criteria
Steqeyma / Yesintek (biosimilars) — Authorization criteria:
Indications for Crohn's disease, plaque psoriasis, psoriatic arthritis, and ulcerative colitis per labeling with required prior therapy trials (e.g., conventional therapies) and specialist prescribing (dermatologist, gastroenterologist, rheumatologist).
For Ustekinumab specifically, require trial/intolerance/contraindication to Steqeyma or Yesintek where applicable per product interchange rules.
Zejula — authorization criteria
Zejula (niraparib) — Authorization criteria:
Advanced or recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer in complete or partial response to platinum-based chemotherapy OR recurrent disease with deleterious/suspected deleterious germline BRCA mutation in response to platinum-based chemotherapy.
Prescribed by an oncologist.
Zelboraf — authorization criteria
Zelboraf (vemurafenib) — Authorization criteria:
Documented unresectable or metastatic melanoma that is BRAF V600E mutation-positive.
Erdheim-Chester Disease (ECD) with documented BRAF V600 mutation per labeled indication.
Exclusion: Not indicated for treatment of wild-type BRAF melanoma.
Prescribed by an oncologist or hematologist.
Zolinza — authorization criteria
Zolinza (vorinostat) — Authorization criteria:
Documented cutaneous T-cell lymphoma with progressive, persistent, or recurrent disease and prior treatment or failure with at least two systemic chemotherapeutic agents for CTCL.
Prescribed by an oncologist or dermatologist experienced in CTCL management.
Ztalmy — authorization criteria
Ztalmy (fenfluramine) — Authorization criteria:
Documented diagnosis of seizures associated with CDKL5 deficiency disorder (CDD).
Prescribed by or in consultation with a neurologist; use consistent with labeled monitoring and age restrictions.
Zurzuvae — authorization criteria
Zurzuvae — Authorization criteria:
Diagnosis of postpartum depression (PPD) and use consistent with labeled short-course treatment.
Prescriber documentation and monitoring per product labeling.
Zydelig — authorization criteria
Zydelig (idelalisib) — Authorization criteria:
Documented diagnosis of relapsed chronic lymphocytic leukemia (CLL) when used in combination with rituximab or other labeled indications; prescribed by a hematologist/oncologist.
Use consistent with safety monitoring and labeling.
Zykadia — authorization criteria
Zykadia (ceritinib) — Authorization criteria:
Documented anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC) per labeled indications.
Prescribed by an oncologist.