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 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 5 of 9 Brand Name Generic Name Drug Classification PALYNZIQ pegvaliase-pqpz Phenylketonuria PANRETIN (gel) alitretinoin HIV/AIDS PEGASYS peginterferon alfa-2a Hepatitis C PEG-INTRON peginterferon alfa-2b Hepatitis C PIFELTRO doravirine HIV/AIDS PLEGRIDY peginterferon beta-1a Multiple Sclerosis POMALYST pomalidomide Oncology PRALUENT alirocumab PCSK-9 Inhibitor PREZCOBIX darunavir-cobicistat HIV/AIDS PREZISTA darunavir HIV/AIDS PROGLYCEM diazoxide Hypoglycemia PROCYSBI cysteamine bitartrate Nephropathic Cystinosis Agent PROMACTA eltrombopag olamine Thrombopoietic Agent PULMOZYME dornase alfa Cystic Fibrosis RASUVO methotrexate Rheumatoid Arthritis/Psoriasis RAVICTI glycerol phenylbutyrate Nitrogen-Binding Agent REBETOL ribavirin* Hepatitis C REBIF interferon beta-1a Multiple Sclerosis RELISTOR methylnaltrexone bromide Specialty GI Drug REPATHA/SURECLICK evolocumab PCSK-9 Inhibitor RESCRIPTOR delavirdine HIV/AIDS RETROVIR zidovudine* HIV/AIDS REVATIO sildenafil* Pulmonary Arterial Hypertension REVLIMID lenalidomide Oncology REYATAZ atazanavir HIV/AIDS RILUTEK riluzole* Sclerosis RUBRACA rucaparib Oncology RUCONEST c1 esterase inhibitor Hereditary Angioedema RYDAPT midostaurin Oncology SABRIL vigabatrin Anticonvulsant SAIZEN somatropin Growth Hormone SAIZENPREP somatropin Growth Hormone SAMSCA tolvaptan Vasopressin Receptor Antagonist Acromegaly/Carcinoid Syndrome/ SANDOSTATIN octreotide VIPomas SELZENTRY maraviroc HIV/AIDS SEROSTIM somatropin HIV/AIDS SIGNIFOR pasireotide Somatostatin/Cushing’s Disease SILIQ brodalumab Monoclonal Antibody SIMPONI golimumab Anti-Tumor Necrosis Factor Drug *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 6 of 9 Brand Name Generic Name Drug Classification SIRTURO bedaquiline Tuberculosis SOMAVERT pegvisomant Acromegaly SOVALDI sofosbuvir Hepatitis C SPRYCEL dasatinib Oncology STELARA ustekinumab Interleukin Blocker STIMATE desmopressin Vasopressin Analogue (nasal spray) STIVARGA regorafenib Oncology STRENSIQ asfotase alfa Hypophosphatasia elvitegravir-cobicistat-emtricitabine- STRIBILD HIV/AIDS tenofovir SUCRAID sacrosidase Enzyme Replacement SUSTIVA efavirenz HIV/AIDS SUTENT sunitinib Oncology SYLATRON peginterferon alfa-2b Oncology SYMDEKO tezacaftor-ivacaftor Cystic Fibrosis SYMFI/SYMFI LO efavirenz-lamivudine-tenofovir HIV/AIDS darunavir-cobicistat-emtricitabine- SYMTUZA HIV/AIDS tenofovir Gonadotropin-Releasing Hormone SYNAREL nafarelin acetate Analog SYNRIBO omacetaxine Oncology SYPRINE trientine Wilson’s Disease TAFINLAR dabrafenib Oncology TAGRISSO osimertinib Oncology TAKHZYRO lanadelumab-fiyo Monoclonal Antibody TALTZ ixekizumab Monoclonal Antibody TALZENNA talazoparib Onclology TARCEVA erlotinib Oncology TARGRETIN bexarotene Oncology (all products) TASIGNA nilotinib Oncology TAVALISSE fostamatinib Spleen Tyrosine Kinase Inhibitor TECFIDERA dimethyl fumarate Multiple Sclerosis TECHNIVIE ombitasvir-paritaprevir-ritonavir Hepatitis C Miscellaneous Neurological TEGSEDI inotersen Therapy TEMODAR temozolomide Oncology TEV-TROPIN somatropin Growth Hormone THALOMID thalidomide Oncology THIOLA tiopronin Kidney Stone Agent TIBSOVO ivosidenib Oncology TIGLUTIK riluzole suspension Sclerosis

*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 7 of 9 Brand Name Generic Name Drug Classification TIVICAY dolutegravir HIV/AIDS TOBI/TOBI PODHALER tobramycin for inhalation Cystic Fibrosis TRACLEER bosentan Pulmonary Arterial Hypertension TREMFYA guselkumab Monoclonal Antibody TRIUMEQ dolutegravir-abacavir-lamivudine HIV/AIDS TRIZIVIR abacavir-lamivudine-zidovudine HIV/AIDS TRUVADA emtricitabine-tenofovir HIV/AIDS TYBOST cobicistat HIV/AIDS TYKERB lapatinib Oncology TYMLOS abaloparatide Osteoporosis/Bones TYVASO treprostinil Pulmonary Arterial Hypertension TYZEKA telbivudine Hepatitis B UPTRAVI selexipag Pulmonary Arterial Hypertension VALCHLOR mechlorethamine Oncology VECAMYL mecamylamine Hypertension VEMLIDY tenofovir HIV/AIDS VENCLEXTA venetoclax Oncology VENTAVIS iloprost Pulmonary Arterial Hypertension VEPESID etoposide Oncology VERSACLOZ clozapine Antipsychotic VERZENIO abemaciclib Oncology VICTRELIS boceprevir Hepatitis C ombitasvir-paritaprevir-ritonavir- VIEKIRA PAK/XR Hepatitis C dasabuvir VIDEX/EC didanosine* HIV/AIDS VIRACEPT nelfinavir HIV/AIDS VIRAMUNE nevirapine* HIV/AIDS VIREAD tenofovir HIV/AIDS VISTOGARD uridine triacetate granule Reversal Agent VITEKTA elvitegravir HIV/AIDS VIZIMPRO dacomitinib Oncology VOTRIENT pazopanib Oncology VOSEVI sofosbuvir-velpatasvir-voxilaprevir Hepatitis C XALKORI crizotinib Oncology XELJANZ/XR tofacitinib Janus Kinase Inhibitor XELODA capecitabine Oncology XENAZINE tetrabenazine Huntington’s Disease XERMELO telotristat etiprate Carcinoid Syndrome Diarrhea XTANDI enzalutamide Oncology XURIDEN uridine triacetate granule Hereditary Orotic Aciduria XYREM gamma hydroxybutyrate Cataplexy *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 8 of 9 Brand Name Generic Name Drug Classification YONSA abiraterone acetate Oncology ZAVESCA miglustat Gaucher’s Disease ZECUITY sumatriptan succinate Anti-Migraine ZEJULA niraparib tosylate Oncology ZELBORAF vemurafenib Oncology ZEPATIER elbasvir-grazoprevir Hepatitis C ZERIT stavudine* HIV/AIDS ZIAGEN abacavir* HIV/AIDS ZINBRYTA daclizumab Monoclonal Antibody ZOLINZA vorinostat Oncology ZOMACTON somatropin Growth Hormone ZORBTIVE somatropin Growth Hormone ZYDELIG Idelaisib Oncology ZYKADIA ceritinib Oncology ZYTIGA abiraterone acetate 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 9 of 9