Specialty Drugs - CareFirst

1 Specialty Drugs (Effe ctive October 1, 2020) Specialty Drugs are medications that may be used to treat rare health conditions and require special handling (such as ref rigeration), administration or monitoring. Specialty Drugs are typically covered f or a one-month supply. CVS Specialty Pharmacy can ship Specialty Drugs to your home or to a retail CVS Pharmacy f or you to pick up. The f ollow ing is a list of Specialty Drugs that may be covered through either your prescription or medical plan; how ever other Specialty Drugs may also be covered. This list represents brand products in CAPS and generic products in low ercase italics. Contact CVS Specialty at 855-264-3237 f or any questions about covered Specialty Drugs .

2 Specialty Drugs AC R OMEGAL Y BYNFEZIA Rx ES PA SI MYCAPSSA * Rx ES PA octreotide acetate (SANDOSTATIN) Rx,MB ES PA m PA SI SANDOSTATIN LAR MB m PA SIGNIFOR LAR MB m PA SOMATULINE DEPOT * MB m PA SOMAVERT * Rx ES PA SI ALCOHOL/OPIOID DEPENDENCY PROBUPHINE * MB NS SUBLOCADE MB NS VIVIT R OL MB NS AL PH A-1 ANTI TRYPSIN DEFICIENCY ARALAST NP * MB mPA^ GLASSIA * MB mPA^ PROLASTIN-C MB m PA^ ZEMAIRA * MB mPA^ AMYOTROPHI C LATERAL SCLEROSIS RADICAVA * MB m PA^ AMYLOI DOSIS ONPATTRO * MB m PA^ TEGSEDI Rx PA SI VYNDAMAX * Rx ES PA VYNDAQEL * Rx ES PA AN EMI A ARANESP Rx,MB ES m PA PA SI EPOGEN Rx,MB ES m PA PA SI MIRCERA Rx,MB m PA PA SI PROCRIT Rx,MB ES m PA PA SI REBLOZYL * MB m PA RETACRIT Rx,MB ES m PA PA SI AS TH MA C IN QAIR * MB m PA^ DUPIXENT Rx ES PA SI FASENRA * MB m PA^ NUCALA * Rx.

3 MB ES m PA^ PA SI XOLAIR * MB m PA^ ATOPI C DERMATI TIS DUPIXENT Rx ES PA SI BATTEN DISEASE BRINEURA MB m PA BOTULINUM TOXINS BOTOX MB mPA NS DYSPORT MB mPA NS MYOBLOC MB mPA NS XEOMIN * MB mPA NS CARDIAC DISORDERS dofetilide (TIKOSYN) Rx ES PA COAGULATION DISORDERS CEPROTIN * MB CRYOPYRI N-ASSOCIATED PERIODIC SYNDROMES ARCALYST * Rx ES PA SI ILAR IS * MB mPA KINERET Rx PA SI CUSHING S SYNDROME ISTURISA Rx PA KORLYM Rx PA SIGN IF OR Rx PA SI C YS TI C F IBROSIS BETHKIS * Rx ES PA CAYSTON * Rx ES PA KALYDECO Rx PA KITABIS PAK Rx ES PA ORKAMBI Rx PA PULMOZYME Rx ES PA SYMDEKO Rx PA TRIKAFTA Rx PA TOBI PODHALER * Rx ES PA tobramycin inhalation solution (TOBI) Rx,MB ES PA m PA DUCHENNE MUSCULAR DYSTROPHY EMFLAZA Rx PA EXONDYS 51 MB m PA^ VILTEPSO MB VYONDYS 53 MB m PA DUPUYTREN S CONTRACTURE XIAFLEX MB m PA ELECTROLYTE DISORDERS CYSTADANE Rx KEVEYIS Rx PA tolvaptan (SAMSCA)

4 * Rx ES PA STRENSIQ Rx PA XU R IDEN Rx GASTROINTESTINAL DISORDERS - OTHER C HOLBAM Rx PA GATTEX * Rx ES PA SI OCALIVA * Rx ES PA SOLESTA * Rx ES PA XERMELO Rx PA GOUT KRYSTEXXA * MB mPA GROWTH HORMONE & RELATED D I S ORD ERS Growth Hormone Disorders GENOTROPIN Rx,MB ES m PA PA SI HUMATROPE Rx,MB ES m PA PA SI NORDITROPIN Rx,MB ES m PA PA SI NUTROPIN AQ Rx,MB ES m PA PA SI OMNITROPE Rx,MB ES m PA PA SI SAIZEN Rx,MB ES m PA PA SI SEROSTIM * Rx,MB ES PA SI ZOMACTON Rx,MB ES m PA PA SI ZORBTIVE Rx,MB ES PA SI I GF-1 Deficiency INCRELEX * Rx,MB ES PA m PA SI HEMATOPOI ETI CS MOZ OBIL * MB HEMOPHI LIA, VON W ILLEBRAND DISEASE & RELATED BLEEDING DISORDERS ADVATE MB m PA ADYNOVATE MB m PA AFSTYLA MB m PA * Indicates Limited Distribution products distributed by CVS Specialty .

5 NS Non- Specialty Indicates Limited Distribution products not distributed by CVS Specialty . PA Prior authorization required for prescription benefits coverage. ES Deliv ered through the CareFirst Exclusive Specialty Pharmacy network. Rx Cov ered under prescription benefit. MB Cov ered under medical benefit. Rx,MB May be cov ered under either prescription or medical benefits. Please consult mPA Prior authorization required for medical benefits coverage. y our plan to determine coverage. mPA^ Prior authorization required for medical benefits coverage and subjected to site of care (outpatient hospital, physician s office, home infusion). SI Self-injectable product. ALPHANATE MB m PA ALPHANINE SD MB m PA ALPROLIX MB m PA BEBULIN MB m PA BENEFIX MB m PA COAGADEX * MB m PA CORIFACT * MB m PA ELOCTATE MB m PA ESPEROCT * MB mPA FEIBA NF MB m PA FIBRYGA MB m PA HELIXATE FS MB m PA HEMLIBRA Rx.

6 MB ES m PA PA SI HEM OF IL M MB m PA HUMATE-P MB m PA IDELVION MB m PA IXIN IT Y MB m PA J IVI MB m PA KOATE-DVI MB m PA KOGENATE FS MB m PA KOVALTRY MB m PA MONOCLATE-P MB m PA MONONINE MB m PA NOVOEIGHT * MB m PA NOVOSEVEN RT MB m PA NUWIQ MB m PA OBIZUR * MB mPA PROFILNINE SD MB m PA REBINYN MB m PA RECOMBINATE MB m PA RIASTAP MB m PA R IXU BIS MB m PA STIMATE Rx PA TRETTEN * MB m PA VONVENDI * MB m PA WILATE MB m PA XYNTHA MB m PA HEPATI TI S C DAKLINZA Rx ES PA EPCLUSA Rx ES PA HARVONI Rx ES PA MAVYRET Rx ES PA PEGASYS Rx ES PA SI PEG-INTRON A Rx ES PA SI REBETOL SOLUTION Rx ES PA ribavirin caps (COPEGUS, REBETOL, RIBASPHERE) Rx ES PA ribavirin tabs (MODERIBA, RIBASPHERE) Rx ES PA SOVALDI Rx ES PA T EC HN IVIE Rx ES PA VIEKIRA PAK Rx ES PA VIEKIRA XR Rx ES PA VOSEVI Rx ES PA ZEPATIER Rx ES PA HEREDI TARY ANGIOEDEMA BERINERT * Rx,MB ES PA m PA SI CINRYZE * Rx,MB ES PA m PA^ SI icatibant acetate (FIRAZYR) * Rx,MB ES PA m PA SI HAEGARDA * Rx,MB ES PA m PA SI KALBITOR * Rx,MB ES PA m PA SI RUCONEST * Rx,MB ES PA m PA SI TAKHZYRO * Rx,MB ES PA mPA SI HEREDI TARY TYROSINEMIA NITYR Rx PA nitisinone (OR F ADIN) Rx PA HIV MEDICATIONS EGRIFTA * Rx ES PA SI FUZEON Rx ES PA SI TROGARZO MB HORMONAL THERAPIES AVEED * MB m PA ELIGARD MB m PA FIRMAGON MB m PA FENSOLVI MB leuprolide acetate (LUPRON)

7 Rx ES PA SI LUPANETA PACK MB m PA LUPRON DEPOT MB m PA NATPARA * Rx ES PA SI SUPPRELIN LA * MB mPA TRELSTAR MB m PA TRIPTODUR MB m PA VANTAS MB m PA ZOLADEX MB m PA HYPOPHOS PHATEMIA CRYSVITA * MB m PA^ I MMUNE DEFICIENCIES & RELATED D I S ORD ERS ASCENIV * MB m PA^ BIVIGAM * MB mPA^ CARIMUNE NF MB m PA^ CUTAQUIQ MB m PA CUVITRU MB m PA^ CYTOGAM MB FLEBOGAMMA DIF MB m PA^ GAMASTAN S/D MB m PA GAMMAGARD LIQUID MB m PA^ GAMMAGARD S/D MB m PA^ GAMMAKED MB m PA^ GAMMAPLEX * MB mPA^ GAMUNEX-C MB m PA^ HEPAGAM B MB HIZENTRA * MB m PA^ HYPERHEP B MB HYPERRHO S/D MB HYQVIA MB m PA^ M IC R HOGAM MB NABI-HB MB OCTAGAM MB m PA^ PANZYGA MB m PA^ PRIVIGEN MB mPA^ REVCOVI Rx,MB SI RHOGAM MB RHOPHYLAC MB VAR IZ IG MB WIN R HO SDF MB XEMBIFY * MB INFECTIOUS DISEASE - OTHER ACTIMMUNE * Rx,MB ES PA m PA SI ALFERON N MB ARIKAYCE Rx NUZYRA * Rx ,MB NS I NF ERTILITY BRAVELLE Rx,MB PA SI CETROTIDE Rx,MB PA SI CHORIONIC GONADOTROPIN Rx,MB PA SI FOLLISTIM AQ Rx,MB PA SI GANIRELIX ACETATE Rx,MB PA SI GONAL-F Rx,MB PA SI MENOPUR Rx,MB PA SI NOVAREL Rx,MB PA SI OVIDR EL Rx,MB PA SI PREGNYL Rx,MB PA SI I NFLAMMATORY BOWEL DISEASE AVSOLA * MB m PA^ C IM Z IA Rx,MB ES PA m PA SI ENTYVIO MB m PA^ HU M IR A Rx ES PA SI INFLECTRA MB m PA^ R EM IC ADE MB m PA^ RENFLEXIS MB m PA^ SIM PON I AR IA MB mPA^ SIMPONI Rx ES PA SI STELARA Rx.

8 MB ES PA m PA SI TYSABRI * MB mPA XELJANZ Rx ES PA I RON OVERLOAD deferoxamine (DESFERAL) MB deferasirox (EXJADE) * Rx ES PA FERRIPROX Rx PA JADENU SPRINKLE * Rx ES PA JADENU * Rx ES PA L I PI D D ISOR DERS JUXTAPID Rx PA KYNAMRO * Rx,MB ES PA SI LI PI D DISORDERS - PC SK 9 I NH IBITORS PRALUENT Rx PA SI NS REPATHA Rx PA SI NS LYS OS OMAL S TORAGE DISOR DERS ADAGEN MB m PA ALDURAZYME * MB mPA^ CERDELGA * Rx ES PA CEREZYME * MB mPA^ CYSTAGON * Rx ES PA CYSTARAN Rx PA ELAPRASE * MB mPA^ ELELYSO * MB mPA^ FABRAZYME * MB mPA^ GALAFOLD Rx PA KANUMA * MB m PA^ LUMIZYME * MB mPA^ MEPSEVII MB m PA^ miglustat Rx ES PA NAGLAZYME * MB mPA^ * Indicates Limited Distribution products distributed by CVS Specialty .

9 NS Non- Specialty Indicates Limited Distribution products not distributed by CVS Specialty . PA Prior authorization required for prescription benefits coverage. ES Deliv ered through the CareFirst Exclusive Specialty Pharmacy network. Rx Cov ered under prescription benefit. MB Cov ered under medical benefit. Rx,MB May be cov ered under either prescription or medical benefits. Please consult mPA Prior authorization required for medical benefits coverage. y our plan to determine coverage. mPA^ Prior authorization required for medical benefits coverage and subjected to site of care (outpatient hospital, physician s office, home infusion). SI Self-injectable product. PROCYSBI Rx PA VIM IZ IM * MB mPA^ VPRIV * MB mPA^ ZAVESCA Rx PA LI PODYSTROPHY MYALEPT Rx,MB PA m PA SI MENTAL HEALTH CONDITIONS SPRAVATO * Rx PA MB m PA NS ZULRESSO * MB m PA MOVEMENT DI SORDERS APOKYN * Rx ES PA SI AUSTEDO Rx ES PA DU OPA MB m PA IN BR IJ A * Rx ES PA INGREZZA Rx PA KYNMOBI * Rx ES PA NORTHERA * Rx ES PA NOURIANZ * Rx, NS NUPLAZID * Rx ES PA tetrabenazine (XENAZINE) * Rx ES PA MULTI PLE S CLEROSIS dalfampridine (AMPYRA) * Rx ES PA AUBAGIO * Rx ES PA AVONEX Rx ES PA SI BAFIERTAM Rx PA BETASERON Rx ES PA SI EXTAVIA Rx ES PA SI GILENYA mg Rx ES PA GILENYA mg Rx PA glatiramer acetate (COPAXONE, GLATOPA)

10 Rx ES PA SI KESIMPTA * Rx ES PA SI LEMTRADA * MB mPA MAVENCLAD * Rx ES PA MAYZENT * Rx ES PA mitoxantrone HCl MB OCREVUS * MB m PA^ PLEGRIDY * Rx ES PA SI REBIF Rx ES PA SI TECFIDERA * Rx ES PA TYSABRI * MB mPA VUMERITY * Rx ES PA ZEPOSIA * Rx ES PA NARCOLEPSY/CATAPLEXY XYREM Rx PA NEUTROPENIA FULPHILA Rx,MB ES PA m PA SI GRANIX Rx,MB ES PA m PA SI LEUKINE Rx,MB ES PA m PA SI NEULASTA Rx,MB ES PA m PA SI NEUPOGEN Rx,MB ES PA m PA SI NIVESTYM Rx,MB ES PA m PA SI UDENYCA Rx,MB ES PA SI ZARXIO Rx,MB ES PA SI ZIEXTENZO *Rx,MB ES PA SI ONCOLOGY - I N JECTAB LE ABRAXANE MB m PA ADCETRIS * MB mPA ALIMTA MB m PA ALIQOPA MB m PA ARZERRA * MB m PA ASPARLAS * MB AVASTIN MB m PA azacitidine (VIDAZ A) Rx,MB ES PA m PA SI AZEDRA MB BAVENCIO * MB mPA BELRAPZO * MB mPA BELEODAQ * MB BENDAMUSTINE HCL MB m PA BENDEKA * MB mPA BESPONSA * MB m PA BLENREP * MB BLINCYTO * MB m PA BORTEZOMIB MB m PA CYRAMZA * MB mPA DARZALEX * MB mPA DARZALEX FASPRO * MB decitabine (DACOGEN) MB ELZONRIS * MB m PA EMPLICITI * MB mPA ENHERTU * MB m PA ERBITUX MB m PA ERWINAZE MB m PA ETOPOPHOS MB etoposide (TOPOSAR) MB EVOMELA * MB FASLODEX MB m PA FOLOTYN MB m PA GAZYVA * MB mPA gemcitabine (GEMZAR, INFUGEM)