CVS Specialty Drug List

1 April 2022 Updated Quarterly Specialty products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time. In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty . Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy. 2022 CVS Specialty . All rights reserved. 75-CTC14953A April 2022 v03302022 Specialty Pharmacy Drug List Page 1 of 4 Specialty Pharmacy Drug List Providing one of the broadest offerings of Specialty pharmaceuticals in the industry The Specialty Pharmacy Drug List is a guide of medications available and distributed through CVS Specialty .

2 Our goal is to help make your life better. With more than 40 years of experience, CVS Specialty provides quality care and service. Our network of pharmacies includes certifications and accreditations from the Joint Commission, Utilization Review Accreditation Commission (URAC), the National Association of Boards of Pharmacy (NABP) and the Accreditation Commission for Health Care (ACHC). These nationally recognized symbols reflect an organization s commitment to meet highest standards of quality, compliance and safety. This list is updated quarterly. Below brand-name products are in CAPS, and generic products are shown in lowercase italics. Prospective Patients: Ready to get started? Enroll to get your medications from CVS Specialty . Health Care Providers: Visit the CVS Specialty website to download enrollment forms or call 1-800-237-2767 (TTY: 711). ACROMEGALY BYNFEZIA PEN octreotide acetate (SANDOSTATIN) SANDOSTATIN LAR SOMATULINE depot SOMAVERT ALPHA-1 ANTITRYPSIN DEFICIENCY ARALAST NP GLASSIA ZEMAIRA AMYLOIDOSIS VYNDAMAX VYNDAQEL ANEMIA ARANESP ENJAYMO EPOGEN PROCRIT REBLOZYL RETACRIT ASTHMA CINQAIR DUPIXENT FASENRA NUCALA TEZSPIRE XOLAIR ATOPIC DERMATITIS ADBRY CIBINQO DUPIXENT RINVOQ BONE DISORDERS OTHER VOXZOGO CARDIAC DISORDERS ARCALYST COAGULATION DISORDERS CEPROTIN CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ARCALYST ILARIS CYSTIC FIBROSIS BRONCHITOL CAYSTON KITABIS PAK PULMOZYME TOBI PODHALER tobramycin (BETHKIS) tobramycin nebulizer (TOBI) ELECTROLYTE DISORDERS tolvaptan (SAMSCA)

3 ENDOCRINE DISORDERS OTHER ACTHAR CORTROPHIN ENZYME DEFICIENCY DISORDERS OTHER nitisinone GASTROINTESTINAL DISORDERS OTHER GATTEX OCALIVA SOLESTA GOUT KRYSTEXXA GROWTH HORMONE & RELATED DISORDERS EGRIFTA EGRIFTA SV GENOTROPIN HUMATROPE INCRELEX NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM SKYTROFA ZOMACTON ZORBTIVE HEMATOPOIETICS MOZOBIL HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BLEEDING DISORDERS ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BENEFIX COAGADEX CORIFACT ELOCTATE ESPEROCT FEIBA FIBRYGA HEMLIBRA HEMOFIL M HUMATE-P IDELVION IXINITY JIVI KOATE KOATE-DVI KOGENATE FS KOVALTRY MONONINE NOVOEIGHT NOVOSEVEN RT NUWIQ OBIZUR PROFILNINE PROFILNINE SD REBINYN RECOMBINATE RIASTAP RIXUBIS SEVENFACT STIMATE TRETTEN VONVENDI WILATE XYNTHA April 2022 Updated Quarterly Specialty products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time.

4 In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty . Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy. 2022 CVS Specialty . All rights reserved. 75-CTC14953A April 2022 v03302022 Specialty Pharmacy Drug List Page 2 of 4 HEPATITIS C EPCLUSA HARVONI LEDIPASVIR-SOFOSBUVIR MAVYRET PEGASYS PEGINTRON ribavirin caps ribavirin tabs SOFOSBUVIR-VELPATASVIR SOVALDI VIEKIRA PAK VOSEVI ZEPATIER HEREDITARY ANGIOEDEMA BERINERT CINRYZE HAEGARDA icatibant acetate (FIRAZYR) KALBITOR RUCONEST TAKHZYRO HORMONAL THERAPIES AVEED ELIGARD FENSOLVI FIRMAGON leuprolide acetate ( lupron )

5 lupron depot NATPARA SUPPRELIN LA TRELSTAR ZOLADEX IMMUNE DEFICIENCIES & RELATED DISORDERS ASCENIV BIVIGAM CUTAQUIG CUVITRU CYTOGAM FLEBOGAMMA DIF GAMASTAN GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX C HEPAGAM B HIZENTRA HYPERHEP B S/D HYPERRHO S/D HYQVIA MICRHOGAM NABI-HB OCTAGAM PANZYGA PRIVIGEN RHOGAM RHOPHYLAC VARIZIG WINRHO SDF XEMBIFY INFECTIOUS DISEASE OTHER ACTIMMUNE ALFERON N INFERTILITY CETROTIDE CHORIONIC GONADOTROPIN FOLLISTIM AQ fyremadel (GANIRELIX acetate ) GONAL-F MENOPUR NOVAREL OVIDREL PREGNYL INFLAMMATORY BOWEL DISEASE AVSOLA CIMZIA ENTYVIO HUMIRA INFLECTRA INFLIXIMAB REMICADE RENFLEXIS SIMPONI ARIA STELARA IV TYSABRI XELJANZ ZEPOSIA IRON OVERLOAD deferasirox (EXJADE, JADENU) deferiprone deferoxamine (DESFERAL) LYSOSOMAL STORAGE DISORDERS ALDURAZYME CERDELGA CEREZYME CYSTAGON ELAPRASE ELELYSO FABRAZYME KANUMA LUMIZYME miglustat NAGLAZYME NEXVIAZYME VIMIZIM VPRIV MENTAL HEALTH CONDITIONS ZULRESSO MOVEMENT DISORDERS apomorphine (APOKYN) AUSTEDO droxidopa (NORTHERA) DUOPA INGREZZA KYNMOBI NUPLAZID RADICAVA SOLIRIS tetrabenazine (XENAZINE) MULTIPLE SCLEROSIS ACTHAR AUBAGIO AVONEX BAFIERTAM BETASERON CORTROPHIN dalfampridine ER (AMPYRA) dimethyl fumarate (TECFIDERA) EXTAVIA GILENYA glatiramer acetate (COPAXONE, glatopa)

6 KESIMPTA LEMTRADA MAVENCLAD MAYZENT mitoxantrone hcl OCREVUS PLEGRIDY PONVORY REBIF TYSABRI VUMERITY ZEPOSIA NEUROLOGICAL DISORDERS ADUHELM NEUROMUSCULAR VYVGART NEUTROPENIA FULPHILA GRANIX LEUKINE NEULASTA NEUPOGEN NIVESTYM NYVEPRIA RELEUKO UDENYCA ZARXIO ZIEXTENZO OCULAR DISORDERS BEOVU EYLEA ILUVIEN LUCENTIS MACUGEN OZURDEX RETISERT SUSVIMO TEPEZZA VABYSMO VISUDYNE ONCOLOGY INJECTABLE ABRAXANE ADCETRIS ARZERRA ASPARLAS AVASTIN azacitidine (VIDAZA) BAVENCIO BELEODAQ BELRAPZO BENDAMUSTINE HYDROCHLORIDE BENDEKA BESPONSA BLINCYTO BORTEZOMIB CYRAMZA DARZALEX DARZALEX FASPRO decitabine (DACOGEN) EMPLICITI ENHERTU ERBITUX EVOMELA FOLOTYN GAZYVA HALAVEN HERCEPTIN April 2022 Updated Quarterly Specialty products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time.

7 In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty . Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy. 2022 CVS Specialty . All rights reserved. 75-CTC14953A April 2022 v03302022 Specialty Pharmacy Drug List Page 3 of 4 HERCEPTIN HYLECTA HERZUMA IMFINZI INTRON A ISTODAX IXEMPRA JEMPERLI JEVTANA KADCYLA KANJINTI KEYTRUDA KHAPZORY KYPROLIS levoleucovorin calcium LUMOXITI MARGENZA mitoxantrone hcl MVASI MYLOTARG OGIVRI ONCASPAR ONTRUZANT OPDIVO OPDUALAG PADCEV PERJETA PHESGO POLIVY PORTRAZZA POTELIGEO PROLEUKIN RIABNI RITUXAN RITUXAN HYCELA ROMIDEPSIN RUXIENCE RYBREVANT SARCLISA SYLVANT SYNRIBO TECENTRIQ TEMODAR temsirolimus (TORISEL) TEPADINA THYROGEN TIVDAK TRAZIMERA TREANDA TRUXIMA valrubicin (VALSTAR) VECTIBIX VELCADE VYXEOS XGEVA YERVOY YONDELIS ZALTRAP ZEPZELCA ZIRABEV zoledronic acid ONCOLOGY ORAL/TOPICAL abiraterone acetate (ZYTIGA) ALECENSA bexarotene (TARGRETIN)

8 BOSULIF BRAFTOVI CABOMETYX capecitabine (XELODA) COMETRIQ COTELLIC DAURISMO ERIVEDGE ERLEADA erlotinib hydrochloride everolimus (AFINITOR) FARYDAK GAVRETO HYCAMTIN IBRANCE IDHIFA imatinib mesylate (GLEEVEC) INLYTA INQOVI INREBIC IRESSA JAKAFI KISQALI KISQALI FEMARA lapatinib ditosylate (TYKERB) lenalidomide (REVLIMID) LENVIMA LONSURF LORBRENA LUMAKRAS LYNPARZA MEKINIST MEKTOVI NERLYNX NEXAVAR NINLARO NUBEQA ODOMZO ONUREG PIQRAY POMALYST PURIXAN RETEVMO ROZLYTREK RUBRACA RYDAPT SCEMBLIX SPRYCEL STIVARGA sunitinib malate (SUTENT) TABRECTA TAFINLAR TAGRISSO TALZENNA TASIGNA temozolomide (TEMODAR) THALOMID VERZENIO VITRAKVI VIZIMPRO VOTRIENT XALKORI XTANDI YONSA ZEJULA ZELBORAF ZOLINZA ZYDELIG ZYKADIA OSTEOPOROSIS EVENITY FORTEO PROLIA TERIPARATIDE TYMLOS zoledronic acid (RECLAST) PAROXYSMAL NOCTURNAL HEMOGLOBINURIA SOLIRIS ULTOMIRIS PHENYLKETONURIA PALYNZIQ sapropterin dihydrochloride (KUVAN) PRE-TERM BIRTH hydroxyprogesterone capro (MAKENA) PSORIASIS AVSOLA CIMZIA COSENTYX ENBREL HUMIRA ILUMYA INFLECTRA INFLIXIMAB OTEZLA OTREXUP RASUVO REMICADE RENFLEXIS SILIQ SKYRIZI STELARA TALTZ TREMFYA XELJANZ PULMONARY ARTERIAL HYPERTENSION ADEMPAS ambrisentan (LETAIRIS) bosentan (TRACLEER) epoprostenol sodium (FLOLAN, VELETRI) OPSUMIT ORENITRAM sildenafil citrate (REVATIO) tadalafil (ADCIRCA, alyq) treprostinil sodium (REMODULIN) TYVASO UPTRAVI VENTAVIS PULMONARY DISORDERS OTHER ESBRIET OFEV RARE DISORDERS OTHER CRYSVITA DOJOLVI ENSPRYNG UPLIZNA RENAL DISEASE cinacalcet hydrochloride (SENSIPAR)

9 PARSABIV tiopronin RESPIRATORY SYNCYTIAL VIRUS SYNAGIS RHEUMATOID ARTHRITIS ACTEMRA AVSOLA CIMZIA ENBREL HUMIRA INFLECTRA INFLIXIMAB KEZVARA April 2022 Updated Quarterly Specialty products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time. In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty . Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy. 2022 CVS Specialty .

10 All rights reserved. 75-CTC14953A April 2022 v03302022 Specialty Pharmacy Drug List Page 4 of 4 OLUMIANT ORENCIA OTREXUP RASUVO REMICADE RENFLEXIS RINVOQ RITUXAN RUXIENCE SIMPONI SIMPONI ARIA TRUXIMA XELJANZ SEIZURE DISORDERS ACTHAR EPIDIOLEX vigabatrin pwd (SABRIL PWD) vigabatrin tabs (SABRIL TABS) SICKLE CELL DISEASE ADAKVEO OXBRYTA SLEEP DISORDERS WAKIX SYSTEMIC LUPUS ERYTHEMATOSUS BENLYSTA MARGENZA THROMBOCYTOPENIA DOPTELET MULPLETA NPLATE PROMACTA UREA CYCLE DISORDERS RAVICTI sodium phenylbutyrate (BUPHENYL) WILSON S DISEASE penicillamine (CUPRIMINE, DEPEN TITRA) trientine (CLOVIQUE, SYPRINE)