Provider Administered Specialty Drugs

1 Provider Administered Specialty Drugs * current 1 /1/22 LDD: Limited Distribution Drug (Dispensing pharmacy can be found here: Limited Distribution Drugs ); PA: Prior Authorization; QL: Quantity Limit 1. These Drugs are covered as Self- Administered or Provider - Administered Specialty Pharmacy Drugs . 2. May coordinate with Florida Cancer Specialists if unwilling to buy/bill. Generics = lower case Brands = Capital Letters *Important information on page 1 Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Important: This is not an all-inclusive list of Drugs covered under the medical benefit nor is it a list of all medical Drugs that require Prior Authorization (PA). These Drugs are covered under the medical policy and medical coverage benefits apply. Prior Authorization requirements may vary.

2 Certain Drugs may not be covered by certain plans. Refer to the member contract benefit for inclusion in the PA program and medication guide for determination of coverage (Prior Authorization Program Information and Forms). If you are a Provider enrolled in our Provider Administered Drug Program (PADP) and wish to buy and bill a drug on this list, please refer to the PADP section of our online Provider manual for a current list of Drugs included. Certain Specialty Drugs may only be available from a specific Specialty pharmacy or pharmacy location. These Drugs are considered Limited Distribution Drugs (LDD). The appropriate dispensing pharmacy can be found here: Limited Distribution Drugs If you have questions or need further assistance after consulting this table, please call: o Customer Service (phone number found on the back of your insurance card) o Provider Contact Center.

3 1-800-727-2227 (health care providers and office staff only) Abecma PA Adakveo PA Actemra IV PA Adagen LDD Aduhelm LDD, PA Aldurazyme LDD, PA Alferon N Alimta PA Aliqopa PA Amondys 45 LDD, PA Apokyn1 PA Aralast NP LDD, PA Aranesp1 PA Arzerra LDD, PA Asceniv PA Asparlas PA Avastin PA Aveed LDD, PA Azedra PA Bavencio LDD, PA Beleodaq LDD, PA Bendamustin RTD PA Bendeka LDD, PA Benlysta LDD, PA Beovu PA Berinert1 LDD, PA Besponsa PA Bexxar Bivigam LDD, PA Blenrep PA Blincyto LDD, PA Boniva PA Botox PA Breyanzi PA Brineura PA Cablivi1 LDD, PA Camcevi Kit PA Ceprotin LDD, PA Ceredase Cerezyme LDD, PA Cimzia PA Cinqair LDD, PA Cinvanti PA Cosela PA Crysvita PA Cyramza LDD, PA Danyelza LDD, PA Darzalex LDD, PA Darzalex Faspro LDD, PA Defitelio PA Dysport PA Elaprase LDD, PA Elelyso LDD, PA Eligard PA Elitek PA Elzonris PA Emend PA Empliciti LDD.

4 PA Enhertu PA Entyvio PA Epogen1 PA epoprostenol LDD, PA Erbitux PA Evenity PA Evkeeza PA Evomela LDD, PA Exondys 51 LDD, PA Eylea LDD, PA Fabrazyme LDD, PA Fasenra PA Faslodex Fensolvi PA Feraheme PA Fibryga1 PA Firmagon Flolan LDD, PA Fulphila1 PA Fusilev GamaSTAN S/D PA Gamifant PA Gammagard1 PA Gammaked1 PA Gamunex C1 PA Gazyva LDD, PA Givlaari PA Glassia LDD, PA Granix1 PA Herceptin PA Herceptin Hylecta PA Herzuma PA HP Acthar Gel1 PA Ilaris LDD, PA Ilumya PA Iluvien LDD, PA Imfinzi LDD, PA Imlygic PA Provider Administered Specialty Drugs * current 1 /1/22 LDD: Limited Distribution Drug (Dispensing pharmacy can be found here: Limited Distribution Drugs ); PA: Prior Authorization; QL: Quantity Limit 1. These Drugs are covered as Self- Administered or Provider - Administered Specialty Pharmacy Drugs . 2. May coordinate with Florida Cancer Specialists if unwilling to buy/bill.

5 Generics = lower case Brands = Capital Letters *Important information on page 1 Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Immune Globulins PA Inmazeb Inflectra PA Infugem PA Intron A1 LDD, PA Injectafer PA Ixifi PA Jelmyto PA Jetrea LDD Jemperli PA Kadcyla PA Kalbitor1 LDD, PA Kanjinti PA Kanuma LDD, PA Keytruda LDD, PA Khapzory PA Korsuva PA Krystexxa LDD, PA Kymriah PA Kyprolis LDD, PA Lartruvo PA Lemtrada LDD, PA Leukine1 PA Libtayo PA Lucentis LDD, PA Lumizyme LDD, PA Lumoxiti LDD, PA Lupaneta Pak PA Lupron1 PA Lupron Depot PA Lutathera PA Luxturna LDD, PA Macrilen PA Macugen LDD, PA Makena LDD, PA Margenza PA Mepsevii PA Metastron PA Metopirone1 LDD Mircera1 LDD, PA Monjuvi PA Monoferric PA Mvasi PA Mylotarg PA Myobloc PA Myozyme LDD, PA Naglazyme LDD, PA Neulasta1 PA Neulasta OnPro PA Neupogen1 PA Nexviazyme LDD, PA Nivestym1 PA Nplate PA Nucala powder for IV LDD, PA Nulibry1 LDD, PA Nuzyra IV LDD Nyvepria1 PA Ocrevus LDD, PA Ogivri PA Onivyde PA Onpattro LDD, PA Ontruzant PA Opdivo LDD, PA Orencia PA Oxlumo LDD, PA Ozurdex LDD, PA Padcev PA Palforzia1 LDD, PA Panzyga PA Parsabiv pemetrexed PA Pemfexy PA Pepaxto PA Perjeta LDD, PA Phesgo PA Polivy PA Portrazza LDD, PA Poteligeo PA Probuphine PA Privigen PA Procrit1 PA Prolastin PA Prolastin-C PA Prolastin-C Liquid PA Prolia PA Provenge PA Quadramet PA Qutenza LDD, PA Radicava PA Reblozyl PA Reclast PA Remicade PA Renflexis LDD, PA Retacrit1 PA Retisert LDD, PA Revatio (IV)

6 PA Revcovi LDD, PA Riabni PA Riastap1 PA Rituxan LDD, PA Rituxan Hycela LDD, PA romidepsin PA Ruxience PA Rybrevant PA Rylaze PA Ryplazim1 LDD, PA Sandostatin LAR/Depot PA Saphnelo LDD, PA Sarclisa PA Scenesse PA Signifor LAR1 LDD, PA, QL Simponi Aria PA Soliris LDD, PA Somatuline Depot LDD, PA Spinraza LDD, PA Spravato LDD, PA Stelara1 PA Sublocade LDD, PA Supprelin LA LDD, PA Sustol PA Sylvant LDD, PA Synagis PA Synribo1 LDD, PA Tecartus PA Tecentriq LDD, PA Tepadina Tepezza LDD, PA Thyrogen LDD Torisel PA Trazimera PA Treanda PA Trelstar Depot PA Trelstar LA PA Triferic AVNU PA Triptodur2 LDD, PA Trodelvy PA Trogarzo Truxima PA Tysabri LDD, PA Udenyca1 PA Ultomiris PA Unituxin PA Uplizna LDD, PA Vantas PA Varubi LDD, PA Vectibix PA Veklury Veletri LDD, PA Provider Administered Specialty Drugs * current 1 /1/22 LDD: Limited Distribution Drug (Dispensing pharmacy can be found here: Limited Distribution Drugs ); PA: Prior Authorization; QL: Quantity Limit 1.

7 These Drugs are covered as Self- Administered or Provider - Administered Specialty Pharmacy Drugs . 2. May coordinate with Florida Cancer Specialists if unwilling to buy/bill. Generics = lower case Brands = Capital Letters *Important information on page 1 Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Viadur PA Vidaza PA Viltepso LDD, PA Vimizim LDD, PA Visudyne LDD, PA Vivitrol Vpriv LDD, PA Vyepti LDD, PA Vyondys 53 LDD, PA Vyxeos PA Xeomin LDD, PA Xgeva PA Xiaflex LDD, PA Xolair 1 LDD, PA, QL Yervoy PA Yescarta PA Yondelis LDD, PA Yutiq PA Zarxio1 PA Zemaira LDD, PA Zepzelca PA Zevalin PA Ziextenzo1 PA Zilretta PA Zinplava PA Zirabev PA Zoladex PA zoledronic acid PA Zolgensma PA Zometa PA Zulresso PA Zynlonta PA