Service Benefit Plan Specialty Pharmacy Drug List

If you are a member or healthcare provider and have specialty drug-specific questions, please call
the Specialty Pharmacy Program at 1- 888-346-3731 weekdays from 7 a.m. to 9 p.m. or weekends
from 8 a.m. to 6:30 p.m. Eastern time. You can also visit fepblue.org/pharmacy.

Specialty drugs are prescribed to treat complex conditions such as multiple sclerosis, hemophilia, hepatitis C and
rheumatoid arthritis. These high-cost drugs also have one or more of the following traits: they are injected or infused (but
some may be taken by mouth); they have unique storage or shipment needs; more education and support are needed to
help you use the drugs properly, and they are usually not stocked at retail pharmacies.

The Blue Cross and Blue Shield Service Benefit Plan maintains a list of specialty prescription drugs. Coverage of and out- of-
pocket costs for drugs on this list may be different under Standard Option, Basic Option, and FEP Blue Focus. Please select your
plan, using the Drug Cost Tool, to confirm your coverage and cost information. This is not an all-inclusive list and is subject to
change without notice. Changes may appear prior to their effective date.

Brand name products are listed in CAPS and generic products are listed in italics. Drugs with an asterisk (*) require
Prior Authorization.

A alyq (ADCIRCA)* BENDEKA * BUPHENYL *

Abiraterone ambrisentan BENEFIX BYLVAY *
(ZYTIGA)* (LETAIRIS) * BENLYSTA * BYOOVIZ *
ACTEMRA* APOKYN * BEOVU * C
ACTHAR* + apomorphine BERINERT * CABOMETYX *
ACTIMMUNE * + (APOKYN) * BESPONSA * CAMPTOSAR
ADAGEN ARALAST NP * BESREMI * CAMZYOS *
ADAKVEO* ARANESP * betaine powder capecitabine
ADALIMUMAB-ADAZ* ARCALYST * (CYSTADANE) (XELODA)*
ADALIMUMAB-FKJP* ARIKAYCE * BETASERON * + carglumic acid
ADBRY* ASCENIV * BETHKIS (CARBAGLU)*
ADCETRIS * AUBAGIO * bexarotene CAYSTON
ADCIRCA* AUGTRYO * (TARGRETIN) * CERDELGA *
adefovir (HEPSERA)* AUSTEDO (XR) * BICNU CEREZYME *
ADEMPAS * AVASTIN * BIMZELEX * cetrorelix
ADVATE AVEED * BIVIGAM * (CETROTIDE) *
ADYNOVATE AVONEX * + bleomycin CETROTIDE *
AFINITOR * AYVAKIT * BLINCYTO * CHORIONIC
AFSTYLA B bortezomib GONADOTROPIN *
ALDURAZYME * BAFIERTAM * (VELCADE)* CIBINQO *
ALECENSA * BALVERSA * bosentan CIMERLI INJ*
ALIMTA BARACLUDE * (TRACLEER) * CIMZIA *
ALPHANATE BCG VACCINE (TICE BOSULIF * cinacalcet
ALPHANINE SD STRAIN) BRAFTOVI * (SENSIPAR) *
ALPROLIX BELEODAQ * BRIUMVI * CINQAIR *
ALTUVIIIO BELRAPZO * BRIXADI * CINRYZE *
ALUNBRIG* bendamustine BRONCHITOL * COAGADEX
ALYMSYS* (TREANDA)* BRUKINSA * COMETRIQ *
*Prior Authorization required
+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025
 COPIKTRA * ELIGARD * FIRMAGON * HUMATE-P
CORIFACT ELITEK FLEBOGAMMA * HUMATROPE * +
CORTROPHIN * ELLENCE FLOLAN * HUMIRA * +
COSENTYX * ELOCTATE FLOLAN STERILE HYALGAN *
COTELLIC * EMPLICITI * DILUENT HYCAMTIN
CRYSVITA * ENBREL * + fludarabine HYMOVIS *
CUTAQUIG * ENDARI * fluorouracil HYPERHEP B
CUVITRU * ENHERTU * FOLLISTIM AQ * HYPERRHO S/D
CYRAMZA * ENJAYMO * FOLOTYN HYQVIA*
CYSTAGON ENSPRYNG * FULPHILA * HYRIMOZ*
cytarabine entecavir FYLNETRA * I
CYTOGAM (BARACLUDE)* IBRANCE *
CYTOVENE ENTYVIO * FUZEON + icatibant (FIRAZYR)
D EPCLUSA * G *+
dalfampridine ER EPIDIOLEX * GAMASTAN * IDELVION
(AMPYRA) * epirubicin (ELLENCE) GAMMAGARD * IDHIFA *
DARZALEX * EPOGEN * GAMMAKED * ILARIS *
DARZALEX FASPRO * epoprostenol GAMMAPLEX * ILUMYA *
DAURISMO * (FLOLAN, GAMUNEX-C * imatinib (GLEEVEC)*
decitabine VELETRI) *
ganirelix * IMFINZI *
(DACOGEN) ERBITUX * GATTEX * IMJUDO *
deferasirox (EXJADE; eribulin (HALAVEN) * GAZYVA * INGREZZA *
JADENU)*
gefitinib (IRESSA)* INLYTA *
deferiprone erlotinib (TARCEVA)*
GEL-ONE * INQOVI *
(FERRIPROX) *
ESBRIET * GELSYN-3 * INREBIC *
DEMSER*
ESPEROCT GENOTROPIN * + IRESSA *
deferoxamine
ETOPOPHOS GENVISC 850 * irinotecan
(DESFERAL)
etoposide (TOPOSAR) GILENYA * (CAMPTOSAR)
deflazacort tabs
EUFLEXXA * GLASSIA * ISTODAX *
(EMFLAZA)*
EVENITY * glatiramer ITOVEBI *
DESFERAL
everolimus (COPAXONE) * + IXEMPRA
desmopressin
(AFINITOR; glatopa (COPAXONE) IXINITY
dichlorphenamide
ZORTRESS) * *+ J
(KEVEYIS)*
EXJADE * GLEEVEC* JADENU *
dimethyl fumarate
EXTAVIA * + GONAL-F * JAKAFI *
(TECFIDERA) *
EYLEA * GRANIX * JAYPIRCA *
dofetilide (TIKOSYN)*
ELYEA HD * H JEVTANA *
DOJOLVI *
F HAEGARDA * JIVI
DOPTELET *
FABRAZYME * HALAVEN * K
droxidopa
FASENRA * HARVONI * KADCYLA *
(NORTHERA) *
FASLODEX * HEMLIBRA KALBITOR *
DUPIXENT *
FEIBA HEMOFIL M KALYDECO *
DUROLANE *
FENSOLVI * HEPAGAM B KANJINTI *
DYSPORT *
FIBRYGA HEPSERA * KANUMA *
E
FILSPARI * HERCEPTIN * KESIMPTA *
EGRIFTA *
ELAPRASE * fingolimod HERCEPTIN KEVEYIS *
(GILENYA) * HYLECTA * KEVZARA *
ELELYSO *
FIRAZYR * + HERZUMA * KEYTRUDA *
ELFABRIO *
HIZENTRA *
*Prior Authorization required
+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025
 KISQALI * MIRENA OFEV * PULMOZYME *
KITABIS mitomycin OGIVRI * PURIXAN
KOATE mitoxantrone OLUMIANT * Q
KOGENATE FS MONONINE OMNITROPE * + R
KOVALTRY MONOVISC * OMVOH * RAVICTI *
KRYSTEXXA * MULPLETA * ONIVYDE * REBIF *
KUVAN * MVASI * ONTRUZANT * REBLOZYL *
KYLEENA MYLOTARG * ONUREG * RECLAST *
KYPROLIS * MYOBLOC * OPDIVO * RELEUKO*
L N OPDUALAG INJ* RELYVRIO*
lanreotide NABI-HB OPSUMIT * REMODULIN *
(SOMATULINE)* NAGLAZYME * ORALAIR * RETACRIT *
lapatinib ditosylate NAVELBINE ORENCIA * RETEVMO *
(TYKERB) * NERLYNX * ORENITRAM * REVATIO *
LARTRUVO nelarabine ORFADIN REVLIMID *
ledip / sofosbuvi (ARRANON) ORGOVYX * RHOGAM
(HARVONI) * NEULASTA * ORKAMBI * RHOPHYLAC
LEMTRADA * NEUPOGEN * ORTHOVISC * RIABNI *
lenalidomide NEXAVAR * OTEZLA * RIASTAP
(REVLIMID)* NEXPLANON OVIDREL * ribavirin *
LENVIMA * NGENLA* P RINVOQ *
LETAIRIS * NINLARO * PADCEV * RITUXAN *
LEUKINE * NIPENT PALFORZIA * RITUXAN HYCELA*
LEUPROLIDE * nitisinone PALYNZIQ * RIVFLOZA *
leuprolide (LUPRON)* (NITYR, pamidronate RIXUBIS
(FUSILEV) ORFADIN) PANZYGA * ROLVEDON *
LILETTA NITYR pazopanib romidepsin
LONSURF * NIVESTYM * (VOTRIENT) * (ISTODAX) *
LORBRENA * NORDITROPIN * + PEGASYS * ROZLYTREK *
LUCENTIS * NORTHERA * PEG-INTRON * RUBRACA *
LUMAKRAS * NOURIANZ * PERJETA * RUCONEST *
LUMIZYME * NOVAREL * PHEBURANE * RUXIENCE *
LUPRON DEPOT * NOVOEIGHT PHESGO * RUZURGI
LYNPARZA * NOVOSEVEN PIQRAY * RYDAPT *
M NPLATE * pirfenidone S
MATULANE NUBEQA * (ESBRIET)* SABRIL *
MAVENCLAD * NUCALA * PLEGRIDY * SAIZEN * +
MAVYRET * NULOJIX POMALYST * SAJAZIR *
MAYZENT * NUPLAZID * PONVORY * SAMSCA *
MEKINIST * NUWIQ PORTRAZZA * SANDOSTATIN *
MEKTOVI * NYVEPRIA * POTELIGEO * SANDOSTATIN LAR *
MENOPUR * O pralatrexate sapropterin
MESNEX OBIZUR (FOLOTYN) (KUVAN) *
Metyrosine OCALIVA * PREGNYL * SARCLISA *
(DEMSER)* OCREVUS * PRIVIGEN * SENSIPAR *
MICRHOGAM OCTAGAM * PROCRIT * SEVENFACT
mifepristone octreotide PROFILNINE SEROSTIM * +
(KORLYM) * (SANDOSTATIN)* PROLIA * sildenafil (REVATIO)*
miglustat (ZAVESCA)* ODOMZO * PROMACTA * SILIQ *
*Prior Authorization required
+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025
 SIMPONI ARIA IV * TECENTRIQ * UDENYCA * XELJANZ *
SIMPONI SC * TEMODAR * ULTOMIRIS * XELJANZ XR *
SKYLA temozolomide UPTRAVI * XELODA *
SKYRIZI * (TEMODAR)*
teriflunomide V XEMBIFY *
SKYTROFA *
sodium (AUBAGIO) * VABYSMO * XENAZINE *
phenylbutyrate teriparatide VANTAS * XEOMIN *
(BUPHENYL) * (FORTEO) * + VARIZIG XGEVA *
sofosbuvir/ velpatasvir tetrabenazine VECTIBIX * XIAFLEX *
(EPCLUSA) * (XENAZINE) *
VEGZELMA* XOLAIR *
SOGROYA * TEZSPIRE *
SOHONOS * THALOMID * VELCADE * XOSPATA *
SOLESTA THERACYS VELETRI * XTANDI *
SOLIRIS * THYROGEN VELSIPITY* XYNTHA
SOMATULINE TICE BCG VEMLIDY Y
DEPOT* TIKOSYN * VENTAVIS * YERVOY *
SOMAVERT tiopronin (THIOLA) *
VERZENIO * YONSA *
sorafenib tiopronin dr (THIOLA
(NEXAVAR) * EC) * vigabatrin (SABRIL)* Z
SOTYKTU* TIVDAK * ZALTRAP *
VIJOICE*
SOVALDI * TOBI ZARXIO *
VIMIZIM *
SPRYCEL * tobramycin (TOBI; ZEJULA *
STELARA * + BETHKIS) vinblastine
ZELBORAF *
STIMUFEND * tolvaptan VINCASAR
(SAMSCA)* ZEMAIRA *
STIVARGA * vincristine
SUBLOCADE * TOPOSAR ZEPATIER *
VISCO-3 *
sunitinib (SUTENT)* topotecan ZEPOSIA *
VITRAKVI *
SUNLENCA * (HYCAMTIN) ZEPZELCA *
TRACLEER * VIVIMUSTA*
SUPARTZ FX * ZIEXTENZO *
SUPPRELIN LA * TRAZIMERA * VIVITROL
TREANDA * ZIRABEV *
SUTENT * VIZIMPRO *
TRELSTAR * ZOLADEX *
SYMDEKO * VONVENDI
TREMFYA * zoledronic acid
SYNAGIS * VOSEVI *
Treprostinil (RECLAST)*
SYNOJOYNT * VOTRIENT *
SYNVISC * (REMODULIN)* ZOLINZA *
TRETTEN VOXOGO *
T ZOMACTON *
TABRECTA * TRIKAFTA * VPRIV *
ZOMETA
tadalafil (ADCIRCA)* TRILURON * VUMERITY *
ZORBTIVE *
TADLIQ SUS* TRIVISC * VYNDAMAX *
ZORTRESS *
TAFINLAR * TROGARZO * VYNDAQEL *
TAGRISSO * ZURZUVAE
TRUSELTIQ * W
TAKHZYRO * ZYDELIG *
TRUXIMA * WAKIX *
TALTZ * ZYKADIA *
TYKERB * WILATE
TALZENNA * ZYMFENTRA *
TARCEVA TYMLOS * WINRHO SDF
ZYNZ *
TARGTETIN GEL * TYSABRI * X
ZYTIGA *
TASIGNA * TYVASO * XALKORI *
tasimelteon U XDEMVY *
(HETLIOZ) *
*Prior Authorization required
+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025
 Limited Distribution Drug List
Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be
available only through specific Preferred retail pharmacies and are referred to as Limited Distribution Drugs. The following list
of Limited Distribution Specialty drugs are not available through CVS Specialty however they may be obtained through a
specific Preferred retail pharmacy. The Specialty Drug Pharmacy Program copayments will apply to these medications.
Please contact the Specialty Pharmacy Program at 1-888-346-3731 for assistance with finding the appropriate pharmacy.

A FILSUVEZ * KRAZATI * PRIALT

AGAMREE * FINTEPLA * L PROCYSBI *
AKEEGA * FIRDAPSE*
LAZCLUZE * PROLASTIN-C *
ALUNBRIG * FOTIVDA*
AMONDYS-45 * FRUZAQLA * LIBTAYO * PYRUKYND *
ARIKAYCE * G LIVMARLI * Q
AYVAKIT * GALAFOLD * LUPKYNIS * QINLOCK *
B GAVRETO * LYTGOBI * R
BAVENCIO * GILOTRIF * M RADICAVA (ORS) *
BESREMI *
GIVLAARI * MATULANE RECORLEV *
BOTOX *
BRUKINSA * H MIRCERA * REVCOVI *
BYLVAY * HETLIOZ * MYALEPT * REZLIDHIA *
C HYFTOR GEL * MYCAPSSA * REZUROCK *
CALQUENCE * I N S
CAMCEVI *
ICLUSIG * NITYR SAJAZIR
CAPRELSA *
CARBAGLU * IMBRUVICA * O SCEMBLIX *
CHOLBAM * IMCIVREE * OGSIVEO * SIGNIFOR (LAR) *
CYSTADANE INBRIJA * OJEMDA* SKYCLARYS *
CYSTADROPS INCRELEX * + OJJAARA * SPEVIGO *
CYSTARAN
ISTURISA * OLPRUVA * STRENSIQ *
D
deflazacort susp * IWILFIN * OPFOLDA* SYNRIBO *
(EMFLAZA SUSP) J ORFADIN T
DIACOMIT * JAVYGTOR * ORGOVYX * TARPEYO *
DAYBUE * JETREA * ORLADEYO * TASCENSO ODT *
E
JOENJA * ORSERDU * TAVALISSE *
EMFLAZA *
EMPAVELI * JUXTAPID* OXERVATE * TAVNEOS *
EVRYSDI * JYNARQUE* P TAZVERIK *
EXKIVITY * K TEPEZZA *
PALFORZIA *
EXONDYS 51 * KINERET * TEPMETKO *
PEMAZYRE *
F TESTOPEL *
KORLYM * pirfenidone 534 mg
FABHALTA * TEVIMBRA *
FERRIPROX * KOSELUGO * POMBILITI*
*Prior Authorization required
+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025
 THIOLA *
THIOLA EC *
TIBSOVO *
TORPENZ *
TRIPTODUR *
TRODELVY *
TUKYSA *
TRUQAP *
TURALIO *
U
V
VALCHLOR *
VANFLYTA *
VENCLEXTA *
vigadrone powder *
VILTEPSO *
VONJO *
VOWST *
VYEPTI *
VYLOY *
VYONDYS 53 *
W
WELIREG *
X
XERMELO *
XOLREMDI *
XPOVIO *
Y
Z
ZAVESCA *
ZILBRYSQ *
ZOKINVY *
ZTALMY*

*Prior Authorization required

+Covered under the pharmacy benefit only

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time
to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on
this document at any time.
Last Revised 01-01-2025