Prime Therapeutics Specialty Drug Management List

Definition of specialty : Specialty medications are generally prescribed for people with complex or ongoing medical conditions such as multiple sclerosis, hemophilia, hepatitis C, and rheumatoid arthritis. These high cost medications also have one or more of the fol- lowing characteristics: injected or infused, but some may be taken by mouth; unique storage or shipment requirements; additional education and support required from a health care professional; and usually not stocked at retail pharmacies.

Autoimmune Cancer - Injectable Ctd. Cancer - Injectable Cancer - Oral Ctd. Endocrine ACTEMRA* BICNU Ctd. LYSODREN* BONIVA IV ARCALYST* BLINCYTO* TRUXIMA MATULANE cinacalcet hcl BENLYSTA* UNITUXIN MEKINIST CRYSVITA* CIMZIA valrubicin MEKTOVI* EVENITY COSENTYX* VALSTAR FORTEO DUPIXENT VECTIBIX MYLERAN H.P. ACTHAR GEL* ENBREL CLOLAR VELCADE NERLYNX* ibandronate sodium ENTYVIO COSMEGEN VIDAZA NEXAVAR* JYNARQUE* FIRDAPSE* CYRAMZA* VYXEOS NILANDRON LUPANETA KIT HUMIRA DACOGEN YERVOY nilutamide NATPARA* ILARIS* YONDELIS NINLARO* octreotide acetate ILUMYA DARZALEX* ZALTRAP NUBEQA PROLIA INFLECTRA ZANOSAR ODOMZO RECLAST KEVZARA ZIRABEV PIQRAY SAMSCA* KINERET* POMALYST* SANDOSTATIN/LAR OLUMIANT* DOXIL PURIXAN* SENSIPAR Cancer - Oral SIGNIFOR/LAR* ORENCIA abiraterone acetate REVLIMID* OTEZLA* doxorubicin liposomal ROZLYTREK* SOMATULINE DEPOT* AFINITOR/DISPERZ SOMAVERT* REMICADE ELITEK ALCENSA* RUBRACA* RENFLEXIS EMPLICITI* RYDAPT TEPEZZA* ALKERAN TRIPTODUR RINVOQ ENHERTU* ALUNBRIG* SIKLOS RUZURGI* ERBITUX SPRYCEL TYMLOS AYVAKIT* XGEVA SILIQ ERWINAZE BALVERSA* STIVARGA* SIMPONI FASLODEX SUTENT XURIDEN* zoledronic acid SIMPONI ARIA FIRMAGON bicalutamide TABLOID SKYRIZI FOLOTYN TAFINLAR ZOMETA BRAFTOVI* STELARA fulvestrant BOSULIF* TAGRISSO* TALTZ* GAZYVA* BRUKINSA* TALZENNA* Enzyme Deficiencies TREMFYA HALAVEN CABOMETYX* TARCEVA* ADAGEN* XELJANZ HERCEPTIN CALQUENCE* TARGRETIN ALDURAZYME IMFINZI* TASIGNA BRINEURA Blood Modifiers ISTODAX* CAPRELSA* TAZVERIK* BUPHENYL ARANESP IXEMPRA CASODEX TEMODAR CARBAGLU* CABLIVI* JEVTANA COMETRIQ* CERDELGA DOPTELET* KADCYLA COPIKTRA* THALOMID* CEREZYME EPOGEN KANJINTI COTELLIC* TIBSOVO* CYSTADANE* FULPHILA KEYTRUDA* toremifene citrate ELAPRASE GIVLAARI* KYPROLIS* DAURISMO* ELELYSO* GRANIX LARTRUVO EMCYT TURALIO* EXONDYS 51* LEUKINE LIPODOX ERIVEDGE* TYKERB FABRAZYME MOZOBIL MARQIBO ERLEADA* VALCHLOR* GALAFOLD* MULPLETA mitomycin erlotinib hydrochloride VENCLEXTA* KANUMA* NEULASTA MVASI VERZENIO* KUVAN* NEUPOGEN NIPENT everolimus VITRAKVI* LUMIZYME* NIVESTYM ONIVYDE FARESTON VIZIMPRO MEPSEVII* NPLATE OGIVRI FARYDAK VOTRIENT miglustat PROCRIT OPDIVO* flutamide XALKORI* MYALEPT* PROMACTA PADCEV GILOTRIF* XELODA NAGLAZYME* REBLOZYL PERJETA GLEEVEC XOSPATA* nitisinone RETACRIT PHOTOFRIN GLEOSTINE XPOVIO* NITYR* UDENYCA POLIVY HERCEPTIN HYLECTA* XTANDI* ORFADIN* ZARXIO PORTRAZZA* HEXALEN YONSA PALYNZIQ* ZIEXTENZO POTELIGEO* HYCAMTIN ZEJULA* PROLEUKIN HYDREA ZELBORAF* PROVENGE* ZOLINZA Cancer - Injectable hydroxyurea RITUXAN IBRANCE* ZYDELIG* ABRAXANE RITUXAN HYCELA ZYKADIA ADCETRIS* ICLUSIG* IDHIFA* ZYTIGA Key ADRIAMYCIN RUXIENCE imatinib mesylate *Limited Distribution Drug ALIMTA SARCLISA* Cystic Fibrosis ALIQOPA IMBRUVICA* SYLATRON* BETHKIS* Brand-name products are ARRANON INREBIC* SYLVANT* CAYSTON* INLYTA* capitalized (e.g. XELODA). SYNRIBO* KALYDECO* ARZERRA* IRESSA* TAXOTERE KITABIS PAK Generic products are AVASTIN* JAKAFI* TECENTRIQ ORKAMBI* lowercase (e.g. capecitabine). KISQALI temsirolimus PULMOZYME BAVENCIO* KISQALI FEMARA SYMDEKO* BELEODAQ* LENVIMA* TORISEL TOBI* BELRAPZO LEUKERAN For more information, call TRAZIMERA tobramycin LONSURF* TREANDA TRIKAFTA* BENDEKA* LORBRENA* TRELSTAR 877.627.6337 BESPONSA LYNPARZA* TRISENOX

This list is subject to change without notice. 4220 © Prime Therapeutics LLC 5/1/20 Product names listed are the property of their respective owners

Prime Therapeutics Specialty Drug Management List

Enzyme Deficiencies Hemophilia Ctd. Multiple Sclerosis Others Ctd. Ctd. REBINYN AMPYRA JETREA* RAVICTI* RECOMBINATE AUBAGIO JUXTAPID* REVCOVI RIXUBIS AVONEX KALBITOR* sodium phenylbutyrate TRETTEN BETASERON KORLYM* STRENSIQ* VONVENDI* COPAXONE KRYSTEXXA SUCRAID* WILATE dalfampridine KYNAMRO VIMIZIM* XYNTHA EXTAVIA LUPRON DEPOT/PED VPRIV* GILENYA leuprolide acetate VYONDYS 53* Hepatitis C GLATOPA MYOBLOC glatiramer acetate ZAVESCA* COPEGUS NORTHERA* LEMTRADA* DAKLINZA NOURIANZ* MAVENCLAD* EPCLUSA NUPLAZID* Fertility & Pregnancy MAYZENT HARVONI NUZYRA* BRAVELLE OCREVUS* INTRON-A* OCALIVA* CETROTIDE PLEGRIDY ledipasvir/sofosbuvir ONPATTRO* chorionic gonadotropin REBIF MAVYRET OXBRYTA* hydroxyprogesterone caproate TECFIDERA* MODERIBA OXERVATE FOLLISTIM AQ TYSABRI* OLYSIO PALFORZIA* GANIRELIX ACETATE VUMERITY* penicillamine GONAL-F/RFF PEGASYS PEG-INTRON PROCYSBI* MAKENA* RADICAVA* MENOPUR REBETOL Pulmonary RIBASPHERE Hypertension RILUTEK NOVAREL riluzole ribavirin ADCIRCA OVIDREL SABRIL* sofosbuvir/velpatasvir ADEMPAS* PREGNYL SIRTURO SOVALDI ALYQ SPINRAZA* TECHNIVIE ambrisentan Growth Hormones SPRAVATO VIEKIRA bosentan GENOTROPIN SUPPRELIN* VOSEVI epoprostenol sodium* HUMATROPE SYNAREL ZEPATIER FLOLAN* INCRELEX* SYPRINE LETAIRIS* NORDITROPIN TAVALISSE* OPSUMIT* NUTROPIN/AQ HIV tetrabenazine ORENITRAM* OMNITROPE EGRIFTA* THROMBATE III REMODULIN* SAIZEN FUZEON TEGSEDI* REVATIO SEROSTIM TROGARZO TIGLUTIK sildenafil citrate ZOMACTON trientine hydrochloride tadalafil ZORBTIVE Immune Globulins VANTAS ASCENIV* TRACLEER* treprostinil* VECAMYL* BIVIGAM vigabatrin Hematological CARIMUNE NF TYVASO* BERINERT* UPTRAVI* VIGADRONE* CUTAQUIG VISTOGARD* CINRYZE* CUVITRU* VELETRI* FIRAZYR VENTAVIS* VIVITROL FLEBOGAMMA VYEPTI* HAEGARDA* GAMASTAN icatibant acetate VYLEESI* GAMASTAN S/D Sleep Disorders VYNDAMAX RUCONEST* GAMMAGARD HETLIOZ* SOLIRIS* VYNDAQEL GAMMAKED WAKIX* XENAZINE* TAKHZYRO* GAMMAPLEX XYREM* ULTOMIRIS* XENLETA* GAMUNEX-C XEOMIN HIZENTRA* Others Hemophilia XERMELO* HYQVIA ADAKVEO XIAFLEX* ADVATE OCTAGAM ALFERON N ZOLGENSMA* ADYNOVATE PANZYGA APOKYN* AFSTYLA PRIVIGEN ARIKAYCE* ALPHANATE XEMBIFY* AUSTEDO ALPHANINE SD BOTOX ALPROLIX Lung Disorders CHENODAL* BEBULIN/VH ACTIMMUNE CHOLBAM BENEFIX ARALAST/NP CLOVIQUE COAGADEX* CINQAIR CUPRIMINE CORIFACT ESBRIET CYSTAGON* ELOCTATE FASENRA CYSTARAN* FEIBA NF/VH FASENRA PEN* deferasirox HELIXATE FS GLASSIA DEPEN TITRATABS HEMLIBRA* NUCALA DIACOMIT HEMOFIL M OFEV DYSPORT Key HUMATE-P PROLASTIN/C ELIGARD IDELVION SYNAGIS EMFLAZA* *Limited Distribution Drug IXINITY XOLAIR ENDARI* Brand-name products are JIVI ZEMAIRA* EPIDIOLEX* KOATE-DVI EXJADE capitalized (e.g. XELODA). KOGENATE FS FERRIPROX* KOVALTRY Macular Degeneration Generic products are BEOVU GAMIFANT* lowercase (e.g. capecitabine). MONOCLATE-P GATTEX* MONONINE EYLEA LUCENTIS GOCOVRI* NOVOEIGHT ILUVIEN* NOVOSEVEN/RT MACUGEN VISUDYNE INBRIJA* For more information, call NUWIQ* INGREZZA* OBIZUR IPRIVASK 877.627.6337 PROFILNINE SD JADENU

This list is subject to change without notice. 4220 © Prime Therapeutics LLC 5/1/20 Product names listed are the property of their respective owners