Prime Therapeutics Specialty Drug Management List

Definition of specialty medications: 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.

Anti-Infective Cancer - Injectable Ctd. Cancer - Injectable Ctd. Cancer - Oral Ctd. Endocrine Ctd. ARIKAYCE* BELEODAQ* VALSTAR NEXAVAR* NATPARA* CAYSTON* BENDEKA* VECTIBIX NILANDRON octreotide acetate SIRTURO BESPONSA VELCADE nilutamide PROLIA BICNU VIDAZA NINLARO* RECLAST Autoimmune BLINCYTO* VYXEOS NUBEQA SAMSCA* YERVOY SANDOSTATIN/LAR ACTEMRA* bortezomib ODOMZO YONDELIS SENSIPAR ARCALYST* carmustine PIQRAY ZALTRAP SIGNIFOR/LAR* BENLYSTA* cladribine POMALYST* ZANOSAR SOMATULINE DEPOT* CIMZIA clofarabine PURIXAN* SOMAVERT* COSENTYX* CLOLAR REVLIMID* TRIPTODUR DUPIXENT COSMEGEN Cancer - Oral ROZLYTREK* TYMLOS ENBREL CYRAMZA* abiraterone acetate RUBRACA* XGEVA ENTYVIO DACOGEN AFINITOR/DISPERZ RYDAPT XURIDEN* FIRDAPSE* dactinomycin ALCENSA* SPRYCEL zoledronic acid HUMIRA DARZALEX* ALKERAN STIVARGA* ZOMETA ILARIS* daunorubicin ALUNBRIG* SUTENT

ILUMYA decitabine BALVERSA* TABLOID INFLECTRA docetaxel bexarotene TAFINLAR Enzyme Deficiencies KEVZARA DOXIL bicalutamide TAGRISSO* ADAGEN* KINERET* doxorubicin BRAFTOVI* TALZENNA* ALDURAZYME OLUMIANT* doxorubicin liposomal BOSULIF* TARCEVA* BRINEURA ORENCIA ELITEK BRUKINSA* TARGRETIN BUPHENYL OTEZLA* EMPLICITI* CABOMETYX* TASIGNA CARBAGLU* REMICADE ERBITUX CALQUENCE* TEMODAR CERDELGA RENFLEXIS ERWINAZE capecitabine temozolomide CEREZYME RINVOQ FASLODEX CAPRELSA* THALOMID* CYSTADANE* RUZURGI* FIRMAGON CASODEX TIBSOVO* ELAPRASE SILIQ FOLOTYN COMETRIQ* toremifene citrate ELELYSO* SIMPONI fulvestrant COPIKTRA* tretinoin EXONDYS 51* SIMPONI ARIA GAZYVA* COTELLIC* TURALIO* FABRAZYME SKYRIZI HALAVEN cyclophosphamide TYKERB GALAFOLD* STELARA HERCEPTIN DAURISMO* VALCHLOR* KANUMA* TALTZ* IMFINZI* EMCYT VENCLEXTA* KUVAN* TREMFYA ISTODAX* ERIVEDGE* VERZENIO* LUMIZYME* XELJANZ IXEMPRA ERLEADA* VITRAKVI* MEPSEVII* JEVTANA erlotinib hydrochloride VIZIMPRO miglustat KADCYLA etoposide VOTRIENT MYALEPT* Blood Modifiers KANJINTI everolimus XALKORI* NAGLAZYME* ARANESP KEYTRUDA* FARESTON XELODA nitisinone CABLIVI* KYPROLIS* FARYDAK XOSPATA* NITYR* DOPTELET* LARTRUVO flutamide XPOVIO* ORFADIN* EPOGEN LIPODOX GILOTRIF* XTANDI* PALYNZIQ* FULPHILA MARQIBO GLEEVEC YONSA RAVICTI* GIVLAARI* mitomycin GLEOSTINE ZEJULA* REVCOVI GRANIX MVASI HERCEPTIN HYLECTA* ZELBORAF* sodium phenylbutyrate LEUKINE NIPENT HEXALEN ZOLINZA STRENSIQ* MOZOBIL ONIVYDE HYCAMTIN ZYDELIG* SUCRAID* MULPLETA OGIVRI HYDREA ZYKADIA VIMIZIM* NEULASTA OPDIVO* hydroxyurea ZYTIGA VPRIV* NEUPOGEN PERJETA IBRANCE* ZAVESCA* NIVESTYM PHOTOFRIN ICLUSIG* Cystic Fibrosis NPLATE POLIVY IDHIFA* BETHKIS* Fertility & Pregnancy PROCRIT PORTRAZZA* imatinib mesylate KALYDECO* BRAVELLE PROMACTA POTELIGEO* IMBRUVICA* KITABIS PAK CETROTIDE REBLOZYL PROLEUKIN INREBIC* ORKAMBI* RETACRIT PROVENGE* INLYTA* PULMOZYME UDENYCA RITUXAN IRESSA* SYMDEKO* ZARXIO RITUXAN HYCELA JAKAFI* TOBI* Key ZIEXTENZO romidepsin KISQALI tobramycin *Limited Distribution Drug SYLATRON* KISQALI FEMARA TRIKAFTA* Cancer - Injectable SYLVANT* LENVIMA* Brand-name products are ABRAXANE SYNRIBO* LEUKERAN Endocrine capitalized (e.g. XELODA). TAXOTERE ADCETRIS* LONSURF* BONIVA IV TECENTRIQ Generic products are ADRIAMYCIN LORBRENA* cinacalcet hcl temsirolimus ALIMTA LYNPARZA* CRYSVITA* lowercase (e.g. capecitabine). teniposide ALIQOPA LYSODREN* EVENITY TORISEL ARRANON MATULANE FORTEO TRELSTAR arsenic trioxide MEKINIST H.P. ACTHAR GEL* TRISENOX For more information, call ARZERRA* MEKTOVI* ibandronate sodium TRUXIMA AVASTIN* mercaptopurine JYNARQUE* UNITUXIN 877.627.6337 azacitidine MYLERAN LUPANETA KIT valrubicin BAVENCIO* NERLYNX* LUPRON DEPOT/PED

This list is subject to change without notice. 4220 © Prime Therapeutics LLC 2/1/20 Product names listed are the property of their respective owners

Prime Therapeutics Specialty Drug Management List

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

This list is subject to change without notice. 4220 © Prime Therapeutics LLC 2/1/20 Product names listed are the property of their respective owners