Pharmacy Prior Authorization Criteria

Oncology Injectable

Indications for Prior Authorization

Criteria

Adcetris, Beleodaq, Enhertu

Administrative

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• Prescribed medication is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Both of the following labeling requirements have been confirmed:
• All components of the FDA approved indication are met (e.g., concomitant use, previous therapy requirements, age limitations, testing requirements, etc.)
AND
• Prescribed medication will be used at a dose which is within FDA recommendations
OR
• Meets the off-label administrative guideline criteria

P & T Revisions

2026-01-02, 2025-12-18, 2025-10-27, 2025-09-30, 2025-08-29, 2025-08-25, 2025-08-11, 2025-07-03, 2025-05-23, 2025-04-30, 2025-04-02, 2025-02-05, 2024-12-20, 2024-12-20, 2024-12-03, 2024-11-06, 2024-10-02, 2024-08-19, 2024-06-21, 2024-05-03, 2024-04-03, 2024-03-22, 2024-01-26, 2024-01-16, 2023-10-24, 2023-10-02, 2023-08-23, 2023-08-01, 2023-07-11, 2023-06-20, 2023-05-01, 2023-03-02, 2022-12-05, 2022-11-14, 2022-09-08, 2022-02-01, 2021-11-19, 2021-09-16, 2021-05-21, 2021-04-12, 2021-02-19, 2020-07-31, 2020-02-20, 2020-01-29

References

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Revision History

• 2026-01-02: New custom standalone EHB guideline.
• 2025-12-18: Addition of Blenrep to guideline. Removal of Lumoxiti.
• 2025-10-27: Update Guideline to add Keytruda Qlex
• 2025-09-30: update guideline
• 2025-08-29: Addition of Rybrevant, Talvey, Trodelvy, and Zynlonta to first criteria bucket of guideline.
• 2025-08-25: Addition of Rybrevant, Talvey, Trodelvy, and Zynlonta to guideline.
• 2025-08-11: Update Guideline to include Zusduri and Lynozyfic. Added operational note.
• 2025-07-03: Addition of Emrelis
• 2025-05-23: Addition of Zynyz to guideline
• 2025-04-30: Addition of Vyloy 300mg strength and Opdualag
• 2025-04-02: Addition of Gazyva and Kimmtrak to guideline.
• 2025-02-05: Addition of Bizengri, Fyarro, and Opdivo Qvantig to guideline
• 2024-12-20: update guideline
• 2024-12-20: update guideline
• 2024-12-03: Addition of Vyloy, Imjudo, Tecvayli, Kyprolis to guideline.
• 2024-11-06: Addition of Tecentriq Hybreza and Sarclisa to guideline
• 2024-10-02: Addition of Elrexfio to guideline
• 2024-08-19: Addition of Columvi, Epkinly, Imfinzi, and Mylotarg to guideline.
• 2024-06-21: Addition of Brand and generic Halaven, Enhertu, Libtayo and Zaltrap.
• 2024-05-03: Addition of Bavencio and Besponsa
• 2024-04-03: Added Istodax and Romidepsin to guideline.
• 2024-03-22: 2024 Annual Review.
• 2024-01-26: update guideline
• 2024-01-16: Addition of Elahere to guideline
• 2023-10-24: Addition of Kadcyla and Tivdak to guideline
• 2023-10-02: Program Update
• 2023-08-23: 2023 Annual Review
• 2023-08-01: Addition of Zepzelca
• 2023-07-11: Removed prescriber requirement. Added Car-T cell products, Folotyn and Brand Pralatrexate to guideline.
• 2023-06-20: Addition of Polivy
• 2023-05-01: Program Update
• 2023-03-02: 2023 Annual Review
• 2022-12-05: Removal of Blenrep from guidelines
• 2022-11-14: Addition of Blenrep to guideline.
• 2022-09-08: Addition of Rylaze
• 2022-02-01: 2022 Annual Review
• 2021-11-19: Addition of Erbitux to guideline
• 2021-09-16: Addition of Opdivo 120mg/12ml strength
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-12: GPI Replication. No change to clinical criteria.
• 2021-02-19: 2021 UM Annual Review.
• 2020-07-31: Added Cyramza to guideline
• 2020-02-20: 2020 UM Annual Review. No changes to criteria.
• 2020-01-29: Added Adcetris, Elzonris, and Lartruvo to guideline.

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