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Specialty Pharmacy Program Drug List

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Specialty Pharmacy Program Drug List Specialty Pharmacy Program Drug List The Specialty Pharmacy Program covers certain drugs commonly referred to as high-cost Specialty Drugs. To receive in- network benefits/coverage for these drugs, these drugs must be dispensed through a select group of contracted specialty pharmacies or your medical provider. Please call the BCBSLA Customer Service number on the back of your member ID card for information about our contracted specialty pharmacies. All specialty drugs listed below are limited to the retail day supply listed in your benefit plan (typically a 30-day supply). As benefits may vary by group and individual plans, the inclusion of a medication on this list does not imply prescription drug coverage. Please refer to your benefit plan for a complete list of benefits, including specific exclusions, limitations and member cost-sharing amounts you are responsible for such as a deductible, copayment and coinsurance. Brand Name Generic Name Drug Classification 8-MOP methoxsalen Psoralen ACTEMRA SC tocilizumab Monoclonal Antibody/Arthritis ACTHAR corticotropin Adrenocortical Insufficiency ACTIMMUNE interferon gamma 1b Interferon ADCIRCA tadalafil Pulmonary Vasodilator ADEMPAS riociguat Pulmonary Vasodilator AFINITOR everolimus Oncology ALECENSA alectinib Oncology ALKERAN (oral) melphalan Oncology ALUNBRIG brigatinib Oncology AMPYRA ER dalfampridine Multiple Sclerosis APTIVUS tipranavir HIV/AIDS APOKYN apomorphine Parkinson's Disease ARCALYST rilonacept Interleukin Blocker/CAPS ATRIPLA efavirenz-emtricitabine-tenofovir HIV/AIDS AUBAGIO teriflunomide Multiple Sclerosis AUSTEDO deutetrabenazine Movement Disorder Therapy AVONEX interferon beta-1a Multiple Sclerosis BARACLUDE entecavir Hepatitis B BENLYSTA belimumab Lupus BETASERON beta-interferon 1B Multiple Sclerosis BETHKIS tobramycin for inhalation Cystic Fibrosis BIKTARVY bictegravir-emtricitabine-tenofovir HIV/AIDS BOSULIF bosutinib Oncology BRAFTOVI encorafenib Oncology BUPHENYL sodium phenylbutyrate Nitrogen-Binding Agent CAPRELSA vandetanib Oncology CABOMETYX cabozantinib Oncology CALQUENCE acalabrutinib Oncology CAYSTON aztreonam lysine Cystic Fibrosis *generic drug is not included in the Specialty Pharmacy Program. 04HQ3922 R01/19 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company Brand Name Generic Name Drug Classification CEENU lomustine Oncology CERDELGA eliglustat Gaucher’s Disease CHEMET succimer Chelating Agent CHENODAL chenodiol Gallstone Solubilizing Agent CHOLBAM cholic acid Bile Acid CIMDUO lamivudine-tenofovir HIV/AIDS CIMZIA certolizumab pegol Anti-Tumor Necrosis Factor Drug CINRYZE C1 esterase inhibitor Hereditary Angioedema COMBIVIR lamivudine-zidovudine* HIV/AIDS COMETRIQ cabozantinib s-malate Oncology COMPLERA emtricitabine-rilpivirine-tenofovir HIV/AIDS COPAXONE glatiramer acetate Multiple Sclerosis COPEGUS ribavirin* Hepatitis C COPIKTRA duvelisib Oncology COSENTYX secukinumab Interleukin-17 Receptor Antagonist COTELLIC cobimetinib fumarate Oncology CRIXIVAN indinavir HIV/AIDS Wilson’s Disease/Cystinuria/ CUPRIMINE penicillamine Rheumatoid Arthritis CYSTADANE betaine Homocystinuria CYSTAGON cysteamine bitartrate Cystinosis Agent CYSTARAN cysteamine Cystine-Depleting Agent DAKLINZA daclatasvir dihydrochloride Hepatitis C DARAPRIM pyrimethamine Antimalarial DDAVP (nasal spray/rhinal desmopressin* Vasopressin Analogue tube) DELSTRIGO doravirine-lamivudine-tenofovir HIV/AIDS DEMSER metyrosine Pheochromocytoma Wilson’s disease/Cystinuria/ DEPEN penicillamine Rheumatoid Arthritis DESCOVY emtricitabine-tenofovir HIV/AIDS DOPTELET avatrombopag maleate Thrombopoietic Agent Atopic Dermatitis – Monoclonal DUPIXENT dupilumab Antibody EDURANT rilpivirine HIV/AIDS EGRIFTA tesamorelin Growth Hormone EMTRIVA emtricitabine HIV/AIDS Anti-Tumor Necrosis Factor Drug/ ENBREL etanercept Arthritis/Psoriasis EMFLAZA deflazacort Corticosteroid ENDARI glutamine Amino Acids – Sickle Cell EPCLUSA sofosbuvir-velpatasvir Hepatitis C *generic drug is not included in the Specialty Pharmacy Program. 04HQ3922 R01/19 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company Page 2 of 9 Brand Name Generic Name Drug Classification EPIVIR lamivudine* HIV/AIDS EPIVIR-HBV lamivudine* Hepatitis B EPZICOM abacavir-lamivudine HIV/AIDS ERIVEDGE vismodegib Oncology ERLEADA apalutamide Oncology ESBRIET pirfenidone Pulmonary Fibrosis EVOTAZ atazanavir-cobicistat HIV/AIDS EXJADE deferasirox Chelating Agent EXTAVIA interferon beta-1b Interferon FARYDAK panobinostat Oncology FERRIPROX deferiprone Iron Overload FIRAZYR icatibant Hereditary Angioedema Parathyroid Hormone for FORTEO teriparatide Osteoporosis/Bones FULYZAQ crofelemer HIV/AIDS FUZEON enfuvirtide HIV/AIDS GALAFOLD migalastat Fabry Disease GATTEX glucagon-like peptide 2 analog Gastrointestinal GENOTROPIN somatropin Growth Hormone elvitegravir-cobicistat-emtricitabine- GENVOYA HIV/AIDS tenofovir alafenamide fumarate glatopa glatiramer acetate Multiple Sclerosis GLEEVEC imatinib Oncology GILENYA fingolimod Multiple Sclerosis GILOTRIF afatinib Oncology GLEOSTINE lomustine Oncology HAEGARDA C1 esterase inhibitor Hereditary Angioedema HARVONI ledipasvir-sofosbuvir Hepatitis C HEMANGEOL propranolol Proliferating Infantile Hemangioma HEPSERA adefovir dipivoxil Hepatitis B HETLIOZ tasimelteon Sedative/Hypnotic HEXALEN altretamine Oncology HUMATROPE somatropin Growth Hormone Monoclonal Antibody/Arthritis/ HUMIRA adalimumab Psoriasis/Crohns/Ankylosing Spondylitis HYCAMTIN topotecan Oncology HYDROXYPROGESTERONE hydroxyprogesterone Hormone CAPROATE IBRANCE palbociclib Oncology ICLUSIG ponatinib Oncology IDHIFA enasidenib mesylate Oncology *generic drug is not included in the Specialty Pharmacy Program. 04HQ3922 R01/19 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company Page 3 of 9 Brand Name Generic Name Drug Classification IMBRUVICA ibrutinib Oncology IMPAVIDO miltefosine Antileishmanial INCIVEK telaprevir Hepatitis C INCRELEX mecasermin Growth Hormone INGREZZA valbenazine Movement Disorder Therapy INLYTA axitinib Oncology INTELENCE etravirine HIV/AIDS INVIRASE saquinavir HIV/AIDS IRESSA getfitinib Oncology ISENTRESS/HD raltegravir HIV/AIDS JADENU/SPRINKLE deferasirox Chelating Agent JAKAFI ruxolitinib Oncology JULUCA dolutegravir-rilpivirine HIV/AIDS JUXTAPID lomitapide Hypercholesterolemia JYNARQUE tolvaptan Vasopressin Receptor Antagonist KALETRA lopinavir-ritonavir HIV/AIDS KALYDECO ivacaftor Cystic Fibrosis KEVEYIS dichlorphenamide Carbonic Anhydrase Inhibitor KEVZARA sarilumab Monoclonal Antibody KINERET anakinra Immunologic Agent KISQALI ribociclib succinate Oncology KISQALI-FEMARA ribociclib succinate-letrozole Oncology KORLYM mifepristone Endocrine/Cushing’s Disease KUVAN sapropterin dihydrochloride Phenylketonuria KYNAMRO mipomersen Hypercholesterolemia LENVIMA lenvatinib Oncology LETAIRIS ambrisentan Pulmonary Arterial Hypertension LEXIVA fosamprenavir HIV/AIDS LITHOSTAT acetohydroxamic acid Urinary Acidifier LOMUSTINE lomustine Oncology LONSURF trifluridine-tipiracil HCl Oncology LORBRENA lorlatinib Oncology LYNPARZA olaparib Oncology LYSODREN mitotane Oncology MAKENA hydroxyprogesterone Hormone MAVYRET glecaprevir-pibrentasvir Hepatitis C MATULANE procarbazine Oncology MEKINIST trametinib Oncology MEKTOVI binimetinib Oncology MESNEX mesna Cytoprotective Agent *generic drug is not included in the Specialty Pharmacy Program. 04HQ3922 R01/19 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company Page 4 of 9 Brand Name Generic Name Drug Classification MESTINON (syrup) pyridostigmine Antimyasthenic MOZOBIL plerixafor Stem Cell Mobilizers MULPLETA lusutrombopag Thrombopoietic Agent MYALEPT metreleptin Leptin Analog MYLERAN busulfan Oncology MYTESI crofelemer HIV/AIDS NATPARA parathyroid hormone Parathyroid Agent NERLYNX neratinib maleate Oncology NEXAVAR sorafenib Oncology NILANDRON nilutamide Oncology NINLARO ixazomib Oncology NITYR nitisinone Heredeitary Tyrosinemia Type 1 NOCDURNA desmopressin Vasopressin Analogue NOCTIVA (nasal spray) desmopressin Vasopressin Analogue NORDITROPIN somatropin Growth Hormone (all products) Neurogenic Orthostatic NORTHERA droxidopa Hypotension NORVIR ritonavir HIV/AIDS dextromethorphan hydrobromide- NUEDEXTA Pseudobulbar Affect quinidine sulfate NUPLAZID pimavenserin Antipsychotic – SSIA NUTROPIN somatropin Growth Hormone (all products) OCALIVA obeticholic acid Primary Biliary Cholangitis ODEFSEY emtricitabine-rilpivirine-tenofovir HIV/AIDS ODOMZO sonidegib phosphate Oncology OFEV nintedanib Pulmonary Fibrosis OLUMIANT baricitinib Janus Kinase Inhibitor OLYSIO simeprevir Hepatitis C OMNITROPE somatropin Growth Hormone OPSUMIT macitentan Pulmonary Arterial Hypertension ORENCIA/ Selective Co-Stimulation abatacept CLICKJECT Modulator for RA ORENITRAM/ER treprostinil Pulmonary Arterial Hypertension ORFADIN nitisinone Tyrosinemia Type 1 ORKAMBI lumacaftor-ivacaftor Cystic Fibrosis OTEZLA apremilast Psoriatic Arthritis Arthritis/Polyarticular Juvenile OTREXUP methotrexate Idiopathic Arthritis/Psoriasis OXSORALEN methoxsalen Psoralen OXSORALEN-ULTRA methoxsalen Psoralen *generic drug is not included in the Specialty
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