Blue Cross and Blue Shield of Nebraska

Prime Therapeutics Specialty Pharmacy 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 following 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 REBLOZYL* ERIVEDGE TAFINLAR LUPRON DEPOT/ PED NUZYRA RETACRIT ERLEADA TAGRISSO MYCAPSSA XENLETA* UDENYCA erlotinib hydrochloride TALZENNA NATPARA ZARXIO everolimus TARCEVA octreotide acetate Autoimmune FARESTON TARGRETIN SAMSCA FARYDAK TASIGNA SANDOSTATIN/ LAR ACTEMRA Cancer – Injectable FOTIVDA* TAZVERIK* SIGNIFOR* ARCALYST* ABECMA* GAVRETO* TEMODAR SIGNIFOR LAR* AVSOLA* AVASTIN GILOTRIF temozolomide SOMATULINE DEPOT BENLYSTA BLENREP* GLEEVEC TEPMETKO* SOMAVERT CIMZIA BREYANZI HEXALEN THALOMID TEPEZZA COSENTYX COSELA HYCAMTIN TIBSOVO* TRIPTODUR* DUPIXENT DANYELZA* IBRANCE Tretinoin TYMLOS ENBREL ENHERTU ICLUSIG* TUKYSA* XGEVA ENTYVIO ERWINAZE* IDHIFA TURALIO* zoledronic acid FIRDAPSE* FIRMAGON imatinib mesylate TYKERB ZOMETA HUMIRA GAZYVA IMBRUVICA* UKONIQ* XURIDEN* ILARIS HYDROXYPROGESTERONE CAPROATE INLYTA VENCLEXTA* ILUMYA JELMYTO* INQOVI VERZENIO INFLECTRA Enzyme Deficiencies JEMPERLI INREBIC VITRAKVI KEVZARA ALDURAZYME KADCYLA IRESSA VIZIMPRO KINERET* AMONDYS 45* MARGENZA* JAKAFI VOTRIENT OLUMIANT BRINEURA* MONJUVI* KISQALI XALKORI ORENCIA BUPHENYL* PADCEV KISQALI FEMARA XELODA OTEZLA CARBAGLU PEPAXTO* KOSELUGO* XOSPATA* REMICADE CERDELGA PHESGO lapatinib ditosylate XPOVIO* RENFLEXIS CEREZYME POLIVY LENVIMA XTANDI RINVOQ ELAPRASE SYLATRON LONSURF YONSA RUZURGI* ELELYSO SARCLISA* LORBRENA ZEJULA* SILIQ EXONDYS 51* SYNRIBO* LYNPARZA ZELBORAF SIMPONI FABRAZYME TECARTUS* LYSODREN* ZOKINVY* SIMPONI ARIA GALAFOLD TECENTRIQ MATULANE* ZOLINZA SKYRIZI KANUMA TRELSTAR DEPOT/ LA MEKINIST ZYDELIG STELARA KUVAN TRODELVY* MEKTOVI ZYKADIA TALTZ LUMIZYME ZEPZELCA* NERLYNX ZYTIGA TREMFYA miglustat ZYNLONTA* NEXAVAR XELJANZ NAGLAZYME NINLARO XELJANZ XR Cystic Fibrosis nitisinone Cancer - Oral NUBEQA BRONCHITOL abiraterone acetate ODOMZO Blood Modifiers CAYSTON AFINITOR / DISPERZ ONUREG (Continued on Page 2) ARANESP KALYDECO ALECENSA ORGOVYX* DOPTELET ORKAMBI ALUNBRIG OXBRYTA CABLIVI* PULMOZYME Key AYVAKIT* PEMAZYRE* EPOGEN SYMDEKO BALVERSA * PIQRAY * Limited distribution FULPHILA TOBI bexarotene POMALYST Brand-name products are GIVLAARI tobramycin BOSULIF QINLOCK* capitalized (e.g. FLOLAN) GRANIX TRIKAFTA BRAFTOVI RETEVMO Generic products are in LEUKINE BRUKINSA* REVLIMID lowercase (e.g. epo- MOZOBIL CABOMETYX ROZLYTREK Endocrine prostenol sodium) MULPLETA CALQUENCE* RUBRACA BYNFEZIA PEN NEULASTA capecitabine RYDAPT CRYSVITA NEUPOGEN CAPRELSA* SPRYCEL EVENITY NIVESTYM COMETRIQ STIVARGA FENSOLVI* NPLATE COPIKTRA* SUTENT FORTEO NYVEPRIA For more information, call COTELLIC TABLOID H.P. ACTHAR GEL PROCRIT DAURISMO TABRECTA ISTURISA* 833.715.0973 PROMACTA LUPANETA KIT This list is subject to change without notice. This list is for medications obtained under the pharmacy benefit. Prime Therapeutics LLC is independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield Association. Inclusion on this list does not guarantee coverage. Some products may be excluded from coverage or require prior authorization before coverage is granted. If you have any questions about this list or about your prescription drug benefits, please call the Member Services number on the back of your member ID card.

4220 NE © Prime Therapeutics LLC 07/1/21 Product names are the property of their respective owners. Blue Cross and Blue Shield of Nebraska

Prime Therapeutics Specialty Pharmacy Drug Management List

NITYR BEBULIN/ VH BIVIGAM REBIF IPRIVASK NULIBRY* BENEFIX CARIMUNE NANOFIL- TECFIDERA JADENU ORFADIN* COAGADEX* TERED TYSABRI JUXTAPID PALYNZIQ CORIFACT CUVITRU VUMERITY KORLYM* RAVICTI ELOCTATE FLEBOGAMMA KRYSTEXXA REVCOVI* FEIBA NF/ VH GAMASTAN Pulmonary Hypertension leuprolide acetate sapropterin dihydrochloride HELIXATE FS* GAMASTAN S/D ADCIRCA LUPKYNIS* STRENSIQ* HEMLIBRA GAMMAGARD LIQUID alyq* NORTHERA SUCRAID* HEMOFIL M GAMMAGARD S/D ADEMPAS NOURIANZ* SYLVANT HUMATE-P GAMMAKED ambrisentan NUPLAZID VILTEPSO* IDELVION GAMMAPLEX bosentan OCALIVA VIMIZIM JIVI GAMUNEX-C epoprostenol sodium ONPATTRO* VPRIV KOATE HIZENTRA FLOLAN OXERVATE* VYONDYS 53* KOATE-DVI HYQVIA LETAIRIS OXLUMO* ZAVESCA KOGENATE FS OCTAGAM OPSUMIT PALFORZIA* KOVALTRY PANZYGA ORENITRAM PROCYSBI Fertility & Pregnancy MONOCLATE-P PRIVIGEN REMODULIN RADICAVA* MONONINE XEMBIFY BRAVELLE REVATIO SABRIL NOVOEIGHT CETROTIDE sildenafil citrate SCENESSE* NOVOSEVEN/ RT chorionic gonadotropin Lung Disorders tadalafil SIRTURO* NUWIQ FOLLISTIM AQ ACTIMMUNE TRACLEER SPINRAZA OBIZUR* GANIRELIX ACETATE ARALAST NP treprostinil TAVALISSE* PROFILNINE SD GONAL-F/ RFF CINQAIR* TYVASO TEGSEDI RECOMBINATE MAKENA ESBRIET UPTRAVI teriparatide RIXUBIS MENOPUR FASENRA VELETRI tetrabenazine SEVENFACT NOVAREL GLASSIA VENTAVIS THIOLA* TRETTEN OVIDREL NUCALA ZEPOSIA THIOLA EC* VONVENDI PREGNYL OFEV THROMBATE III* WILATE PROLASTIN-C* Others UPLIZNA* XYNTHA Growth Hormones SYNAGIS ALFERON N* VALCHLOR XOLAIR GENOTROPIN ALKINDI SPRINKLE* VECAMYL* Hepatitis C ZEMAIRA HUMATROPE APOKYN vigabatrin DAKLINZA INCRELEX ARIKAYCE vigadrone* EPCLUSA NORDITROPIN Macular Degeneration AUSTEDO VISTOGARD* HARVONI NUTROPIN/AQ LUCENTIS BOTOX VIVITROL INTRON-A OMNITROPE MACUGEN CHENODAL* VYLEESI* LEDIPASVIR/SOFOSBUVIR SAIZEN VISUDYNE CHOLBAM* VYNDAMAX MAVYRET SEROSTIM CUTAQUIG VYNDAQEL MODERIBA ZOMACTON CYSTADROPS* XENAZINE PEGASYS Migraine ZORBTIVE deferasirox XERMELO* PEGINTRON VYEPTI* deferiprone* XIAFLEX* REBETOL DIACOMIT* Hematological RIBASPHERE Multiple Sclerosis DOJOLVI BERINERT ribavirin AUBAGIO droxidopa CINRYZE SOFOSBUVIR/ AVONEX DURYSTA Key FIRAZYR VELPATASVIR BAFIERTAM ELIGARD * Limited distribution HAEGARDA SOVALDI BETASERON ENDARI* icatibant acetate TECHNIVIE Drugs in BOLD are pre- COPAXONE EMFLAZA ferred products ORLADEYO* VIEKIRA dimethyl fumarate ENSPRYNG Brand-name products are SOLIRIS VOSEVI EXTAVIA EVKEEZA* capitalized (e.g. FLOLAN) ULTOMIRIS ZEPATIER GILENYA EVRYSDI glatiramer acetate Generic products are in EXJADE lowercase (e.g. epo- Hemophilia HIV glatopa FERRIPROX* prostenol sodium) ADVATE CABENUVA KESIMPTA FINTEPLA* ADYNOVATE EGRIFTA LEMTRADA GAMIFANT* AFSTYLA FUZEON MAVENCLAD GATTEX ALPHANATE MAYZENT IMCIVREE* For more information, call ALPHANINE SD Immune Globulin OCREVUS INBRIJA* PLEGRIDY ALPROLIX ASCENIV INGREZZA* 833.715.0973 PONVORY

This list is subject to change without notice. This list is for medications obtained under the pharmacy benefit. Prime Therapeutics LLC is independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield Association. Inclusion on this list does not guarantee coverage. Some products may be excluded from coverage or require prior authorization before coverage is granted. If you have any questions about this list or about your prescription drug benefits, please call the Member Services number on the back of your member ID card.

4220 NE © Prime Therapeutics LLC 07/1/21 Product names are the property of their respective owners. Blue Cross and Blue Shield of Nebraska

Prime Therapeutics Specialty Pharmacy Drug Management List

XURIDEN* XYREM

Sleep Disorder HETLIOZ WAKIX XYWAV

Key * Limited distribution Drugs in BOLD are pre- ferred products Brand-name products are capitalized (e.g. FLOLAN)

Generic products are in lowercase (e.g. epo- prostenol sodium)

For more information, call 833.715.0973

This list is subject to change without notice. This list is for medications obtained under the pharmacy benefit. Prime Therapeutics LLC is independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Nebraska, an independent licensee of the Blue Cross and Blue Shield Association. Inclusion on this list does not guarantee coverage. Some products may be excluded from coverage or require prior authorization before coverage is granted. If you have any questions about this list or about your prescription drug benefits, please call the Member Services number on the back of your member ID card.

4220 NE © Prime Therapeutics LLC 07/1/21 Product names are the property of their respective owners. Discrimination is Against the Law

Blue Cross and Blue Shield of Nebraska complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Nebraska does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Nebraska: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at 1-888-488-9850, TTY 711.

If you believe that Blue Cross and Blue Shield of Nebraska has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Manager, Corporate Compliance Blue Cross and Blue Shield of Nebraska P.O. Box 3248 Omaha, NE 68180-0001 1-888-488-9850, TTY: 711 Fax: 1-402-392-4130 [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Manager, Corporate Compliance, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

NE 16061 AUG 16 H3170_C_NENonDiscrimNoticeR2 FVNR 0816 Multi-language Interpreter Services

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-488-9850 (TTY: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-488-9850 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。 請致電 1-888-488-9850（TTY: 711）。

ﻣﻠﺣوظﺔ: إذا ﻛﻧت ﺗﺗﺣدث اﻟﻌرﺑﯾﺔ، ﻓﺈن ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ ﺗﺗواﻓر ﻟك ﺑﺎﻟﻣﺟﺎن. اﺗﺻل ﺑرﻗم :Arabic 9850-488-888-1 (رﻗم ھﺎﺗف اﻟﺻم واﻟﺑﻛم: 711).

Karen: 1-888-488-9850 (TTY: 711)

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-488-9850 (ATS: 711).

Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-488-9850 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-488-9850 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-488-9850 (TTY: 711) 번으로 전화해 주십시오.

Nepali: 鵍यान �दनुहोस्: य�द तपा�ले नेपाली बो쥍नु�ꅍछ भने, तपा�को लािग भाषा सहायता सेवाह� िन:शु쥍क उपल녍ध छन्। 1-888-488-9850 (TTY: 711) मा फोन गनु셍होस्।

NE 16067 OCT 16 H3170_C_NEHMOMultilangInsrtR1 CMS Accepted 08302016 Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-488-9850 (телетайп: 711).

Laotian: ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວົ້ າພາສາ ລາວ, ການບໍ ິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່ າ, ແມ່ ນມີ ພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-888-488-9850 (TTY: 711).

ﺋﺎﮔﺎداری: ﺋﮭﮕﮭﺮ ﺑﮭ زﻣﺎﻧﯽ ﮐﻮردی ﻗﮭﺴﮭ ،دەﮐﮭﯿﺖ ﺧﺰﻣﮭﺘﮕﻮزارﯾﮭﮑﺎﻧﯽ ﯾﺎرﻣﮭﺘﯽ ،زﻣﺎن :Kurdish ،ﺑﮭﺨﯚڕاﯾﯽ ﺑﯚ ﺗﯚ ﺑﮭﺮدەﺳﺘﮭ. ﭘﮭﯿﻮەﻧﺪی ﺑﮭ TTY: 711) 1-888-488-9850) .ﺑﮑﮭ

ﺗﻮﺟﮫ: اﮔﺮ ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺻﺤﺒﺖ ﻣﯽﮐﻨﯿﺪ، ﺧﺪﻣﺎت و ﮐﻤﮏھﺎی زﺑﺎﻧﯽ راﯾﮕﺎن ﺑﺮای ﺷﻤﺎ ﻣﻮﺟﻮد اﺳﺖ. :Persian ﺑﺮای ﮐﺴﺐ اطﻼﻋﺎت ﺑﯿﺸﺘﺮ، ﺑﺎ ﺷﻤﺎره TTY: 711) 1-888-488-9850) ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ.

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-888-488-9850（TTY: 711）まで、お電話にてご連絡ください。