2021 Specialty Drug List

What is a specialty drug? Specialty drugs treat complex, chronic conditions. A nurse or pharmacist will often support their use during treatment. These drugs may be injected, infused or taken by mouth. You may need to refrigerate them. They are often expensive and the list may change throughout the year. How to use this guide You must fill these drugs at UVA Specialty Pharmacy (1-800-251-3627). For questions regarding the requirements and limitations of your pharmacy benefits and insurance plan, please contact your Aetna One Advocate team at 1-800-987-9072. How to get started with a specialty pharmacy All specialty medications except Limited Distribution Drugs (LDD) must be filled through the UVA Specialty Pharmacy. Contact them at 1-434-297-5500. Specialty drugs are are limited to a 30-day supply. For Limited Distribution Drugs (LDD) that cannot be filled through the UVA Specialty Pharmacy, order your prescriptions through CVS Specialty Pharmacy. What you can expect to pay Tier 1 drugs are specialty generics (lowest cost for specialty drugs); Tier 2 drugs are preferred specialty drugs (lower cost for specialty drugs); Tier 3 are non-preferred specialty drugs (higher cost for non-preferred specialty drugs).

ACROMEGALY ELECTROLYTE DISORDERS HEMOPHILIA OCTREOTIDE ACETATE 1 KEVEYIS LDD 3 REBINYN LDD 2 SANDOSTATIN 3 SAMSCA LDD 3 RECOMBINATE LDD 3 SOMATULINE DEPOT LDD 2 TOLVAPTAN 1 RIASTAP LDD 3 ALPHA-1 ANTITRYPSIN DEFICIENCY GASTROINTESTINAL DISORDERS-OTHER RIXUBIS LDD 3 PROLASTIN-C LDD 2 CHENODAL LDD 3 STIMATE 3 AMYLOIDOSIS CHOLBAM LDD 3 TRETTEN LDD 3 ONPATTRO LDD 3 GATTEX LDD 3 WILATE LDD 3 TEGSEDI LDD 2 OCALIVA LDD 3 XYNTHA LDD 3 VYNDAMAX LDD 3 SOLESTA LDD 3 XYNTHA SOLOFUSE LDD 3 ANEMIA GOUT HEPATITIS B ARANESP ALBUMIN FREE 2 KRYSTEXXA LDD 3 ADEFOVIR DIPIVOXIL 1 RETACRIT 2 GROWTH HORMONE AND RELATED DISORDERS BARACLUDE 2 ASTHMA EGRIFTA LDD 3 ENTECAVIR 1 DUPIXENT 2 EGRIFTA SV LDD 3 LAMIVUDINE 1 FASENRA LDD 2 INCRELEX LDD 3 VEMLIDY 2 FASENRA PEN LDD 2 NORDITROPIN FLEXPRO 2 HEPATITIS C NUCALA LDD 2 SEROSTIM LDD 3 EPCLUSA 2 XOLAIR LDD 2 ZORBTIVE 3 HARVONI 2 ATOPIC DERMATITIS HEMATOPOIETICS MODERIBA 1 DUPIXENT 2 MOZOBIL LDD 3 MODERIBA 1200 DOSE PACK 3 BONE DISORDERS - OTHER HEMOPHILIA PEGINTRON 3 STRENSIQ LDD 3 ADYNOVATE LDD 2 REBETOL 3 CARDIAC DISORDERS AFSTYLA LDD 3 RIBASPHERE 1 DOFETILIDE 1 ALPHANATE LDD 3 RIBASPHERE RIBAPAK 3 TIKOSYN 3 ALPHANATE/VON WILLEBRAND LDD 3 RIBAVIRIN 1 COAGULATION DISORDERS ALPHANINE SD LDD 3 SOVALDI 3 CEPROTIN LDD 3 BENEFIX LDD 3 VOSEVI 2 CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES COAGADEX LDD 3 HEREDITARY ANGIOEDEMA ARCALYST LDD 3 CORIFACT LDD 3 CINRYZE LDD 3 ILARIS LDD 3 FEIBA LDD 3 FIRAZYR LDD 2 CUSHING'S SYNDROME FIBRYGA LDD 3 HAEGARDA LDD 3 KORLYM LDD 3 HEMLIBRA LDD 3 ICATIBANT ACETATE 1 SIGNIFOR LDD 3 HEMOFIL M LDD 3 KALBITOR LDD 3 CYSTIC FIBROSIS HUMATE-P LDD 3 RUCONEST LDD 2 BETHKIS LDD 2 IDELVION LDD 3 TAKHZYRO LDD 2 CAYSTON LDD 3 IXINITY LDD 3 HEREDITARY OROTIC ACIDURIA KALYDECO LDD 3 JIVI LDD 2 XURIDEN LDD 3 KITABIS PAK LDD 3 KOATE LDD 3 HORMONAL THERAPIES ORKAMBI LDD 3 KOATE-DVI LDD 3 AVEED LDD 3 PULMOZYME LDD 3 KOGENATE FS LDD 2 ELIGARD 2 SYMDEKO LDD 3 KOVALTRY LDD 2 FENSOLVI LDD 3 TOBRAMYCIN INHALATION 1 MONOCLATE-P 3 FIRMAGON 3 TRIKAFTA LDD 3 MONONINE LDD 3 LEUPROLIDE ACETATE 1 DUPUYTREN'S CONTRACTURE NOVOEIGHT LDD 2 LUPANETA PACK 3 XIAFLEX LDD 3 NOVOSEVEN RT LDD 3 LUPRON DEPOT (1-MONTH) 3 NUWIQ LDD 2 LUPRON DEPOT (3-MONTH) 3 PROFILNINE LDD 3 LUPRON DEPOT-PED (1-MONTH 3 PROFILNINE SD LDD 3 LUPRON DEPOT-PED (3-MONTH) 3

1 05.03.153.1B (04/2021) HORMONAL THERAPIES HUMAN IMMUNODEFICIENCY VIRUS LYSOSOMAL STORAGE DISORDER NATPARA LDD 3 VIDEX EC 3 ALDURAZYME LDD 3 SUPPRELIN LA LDD 3 VIRACEPT 3 BRINEURA LDD 3 TRELSTAR MIXJECT 3 VIRAMUNE 3 CERDELGA LDD 2 VANTAS LDD 3 VIRAMUNE XR 3 CEREZYME LDD 2 ZOLADEX 3 VIREAD 3 CYSTAGON LDD 2 HUMAN IMMUNODEFICIENCY VIRUS ZIAGEN 3 CYSTARAN LDD 3 ABACAVIR 1 ZIDOVUDINE 1 ELAPRASE LDD 3 ABACAVIR-LAMIVUDINE 1 IMMUNE DEFICIENCIES AND RELATED DISORDERS FABRAZYME LDD 3 ABACAVIR-LAMIVUDINE-ZIDOVUDINE 1 BIVIGAM LDD 3 GALAFOLD LDD 3 APTIVUS 3 CARIMUNE NANOFILTERED 3 KANUMA LDD 3 ATAZANAVIR 1 CYTOGAM 3 LUMIZYME LDD 3 ATRIPLA 3 FLEBOGAMMA DIF LDD 3 MEPSEVII LDD 3 BIKTARVY 2 GAMASTAN S/D LDD 3 MIGLUSTAT 1 CIMDUO 2 GAMMAGARD LIQUID LDD 3 NAGLAZYME LDD 3 COMBIVIR 3 GAMMAGARD S/D LDD 3 VIMIZIM LDD 3 CRIXIVAN 3 GAMMAKED LDD 3 VPRIV LDD 3 DESCOVY 2 GAMMAPLEX LDD 3 ZAVESCA LDD 3 DIDANOSINE 1 GAMUNEX-C LDD 3 MISCELLANEOUS DOVATO 2 HEPAGAM B 3 ADAGEN LDD 3 EDURANT 2 HIZENTRA LDD 3 CYSTADANE LDD 3 EFAVIRENZ 1 HYPERHEP B LDD 3 NITISINONE 1 EFAVIRENZ-EMTRICITABINE-TENOFOVIR 1 HYPERRHO S/D LDD 3 NITYR LDD 3 EFAVIRENZ-LAMIVUDINE-TENOFOVIR 1 HYPERRHO S/D MINI-DOSE LDD 3 ORFADIN LDD 2 EMTRICITABINE 1 MICRHOGAM ULTRA-FILTERED 3 MOVEMENT DISORDERS EMTRICITABINE-TENOFOVIR 1 NABI-HB LDD 3 AUSTEDO LDD 2 EMTRIVA 2 OCTAGAM LDD 3 DROXIDOPA ^ 1 EPIVIR 3 PRIVIGEN LDD 3 DUOPA LDD 3 EPZICOM 3 REVCOVI LDD 3 INBRIJA LDD 2 EVOTAZ 2 RHOGAM ULTRA-FILTERED PLUS 3 INGREZZA LDD 2 FOSAMPRENAVIR CALCIUM 1 RHOPHYLAC LDD 3 NUPLAZID LDD 3 FUZEON LDD 2 VARIZIG 3 RADICAVA LDD 3 GENVOYA 2 WINRHO SDF 3 TETRABENAZINE 1 INTELENCE 2 INFECTIOUS DISEASE - OTHER MULTIPLE SCLEROSIS INVIRASE 3 ACTIMMUNE LDD 3 AMPYRA LDD 3 ISENTRESS 2 ALFERON N 3 BETASERON 2 ISENTRESS HD 2 ARIKAYCE LDD 3 COPAXONE LDD 2 JULUCA 3 INFERTILITY DALFAMPRIDINE ER 1 KALETRA 3 CETROTIDE 2 DIMETHYL FUMARATE LDD 1 LAMIVUDINE 1 GANIRELIX ACETATE 3 DIMETHYL FUMARATE STARTER 1 LAMIVUDINE-ZIDOVUDINE 1 GONAL-F 2 GILENYA 2 LEXIVA 3 GONAL-F RFF 2 GLATIRAMER ACETATE 1 LOPINAVIR-RITONAVIR 1 GONAL-F RFF REDIJECT 2 GLATOPA 1 NEVIRAPINE 1 MENOPUR 3 KESIMPTA LDD 2 NEVIRAPINE ER 1 OVIDREL 2 MAVENCLAD LDD 3 NORVIR 2 INFLAMMATORY BOWEL DISEASE MAYZENT LDD 2 ODEFSEY 2 HUMIRA PEDIATRIC CROHNS 2 MAYZENT STARTER PACK LDD 2 PREZCOBIX 2 HUMIRA PEN 2 MITOXANTRONE HCL 1 PREZISTA 2 HUMIRA PEN-CD/UC/HS 2 OCREVUS LDD 2 RESCRIPTOR 3 HUMIRA PEN-PEDIATRIC UC 2 REBIF 2 RETROVIR 3 REMICADE LDD 2 REBIF REBIDOSE 2 RETROVIR IV INFUSION 3 STELARA LDD 2 REBIF REBIDOSE TITRATION 2 REYATAZ 3 IRON OVERLOAD REBIF TITRATION PACK 2 RITONAVIR 1 DEFERASIROX 1 TYSABRI LDD 2 SELZENTRY 3 DEFEROXAMINE MESYLATE 1 VUMERITY LDD 2 STAVUDINE 1 DESFERAL 3 ZEPOSIA LDD 2 SUSTIVA 3 EXJADE LDD 3 ZEPOSIA STARTER KIT LDD 2 SYMFI 3 FERRIPROX LDD 3 ZEPOSIA 7-DAY STARTER PACK LDD 2 SYMFI LO 3 FERRIPROX TWICE-A-DAY LDD 3 MUSCULAR DYSTROPHY SYMTUZA 2 JADENU LDD 3 EXONDYS 51 LDD 3 TEMIXYS 2 JADENU SPRINKLE LDD 3 NEUROMUSCULAR TIVICAY 2 LIPID DISORDERS EVRYSDI LDD 3 TIVICAY PD 2 JUXTAPID LDD 3 SPINRAZA LDD 3 TRIUMEQ 2 PRALUENT 2 ZOLGENSMA 10.1-10.5 KG LDD 3 TRIZIVIR 3 LIPODYSTROPHY NEUTROPENIA TROGARZO LDD 3 MYALEPT LDD 3 LEUKINE 3 TRUVADA 2 NIVESTYM 2 TYBOST 3 ZIEXTENZO LDD 2 VIDEX 3

2 05.03.153.1B (04/2021) OCULAR DISORDERS ONCOLOGY ONCOLOGY EYLEA LDD 2 INTRON A LDD 3 THALOMID LDD 2 ILUVIEN LDD 3 IRESSA LDD 2 THYROGEN LDD 3 JETREA LDD 3 ISTODAX (OVERFILL) LDD 3 TIBSOVO LDD 3 LUCENTIS LDD 2 IXEMPRA KIT 3 TORISEL 3 MACUGEN LDD 3 JAKAFI LDD 3 TREANDA LDD 3 OXERVATE LDD 3 JELMYTO LDD 3 TRODELVY LDD 3 OZURDEX LDD 3 JEVTANA LDD 3 TUKYSA LDD 3 RETISERT LDD 3 KADCYLA LDD 3 TYKERB LDD 3 TEPEZZA LDD 3 KEYTRUDA LDD 3 UNITUXIN LDD 3 VISUDYNE LDD 3 KISQALI 2 VALRUBICIN 1 ONCOLOGY KISQALI FEMARA 2 VALSTAR LDD 3 ABIRATERONE ACETATE 1 KOSELUGO LDD 3 VECTIBIX 3 ADCETRIS LDD 3 KYMRIAH LDD 3 VELCADE 2 AFINITOR 2 LAPATINIB DITOSYLATE 1 VENCLEXTA LDD 3 AFINITOR DISPERZ 2 LARTRUVO LDD 3 VERZENIO LDD 3 ALECENSA LDD 2 LENVIMA LDD 3 VIDAZA LDD 3 ALUNBRIG LDD 2 LEVOLEUCOVORIN 1 VISTOGARD LDD 2 ARZERRA LDD 3 LIBTAYO LDD 3 VITRAKVI LDD 3 ASPARLAS LDD 3 LONSURF LDD 3 VORAXAZE LDD 3 AVASTIN LDD 3 LORBRENA LDD 3 VOTRIENT LDD 2 AZACITIDINE 1 LUMOXITI LDD 3 VYXEOS LDD 3 AZEDRA LDD 3 LUTATHERA LDD 3 XALKORI LDD 3 BALVERSA LDD 3 LYNPARZA LDD 2 XELODA LDD 3 BAVENCIO LDD 3 MARQIBO LDD 3 XERMELO LDD 3 BELEODAQ LDD 3 MATULANE LDD 2 XGEVA 3 BENDAMUSTINE HYDROCHLORIDE 3 MEKINIST LDD 3 XOSPATA LDD 2 BENDEKA LDD 3 MEKTOVI LDD 3 XTANDI LDD 2 BESPONSA LDD 3 MUGARD LDD 2 YERVOY LDD 3 BEXAROTENE 1 MYLOTARG LDD 3 YESCARTA LDD 3 BLINCYTO LDD 3 NERLYNX LDD 3 YONDELIS LDD 3 BOSULIF 2 NEXAVAR LDD 3 YONSA LDD 2 BRAFTOVI LDD 3 NINLARO LDD 2 ZALTRAP LDD 3 BREYANZI LDD 3 NUBEQA LDD 2 ZEJULA LDD 2 BRUKINSA LDD 3 ODOMZO LDD 2 ZELBORAF LDD 3 CABOMETYX LDD 2 ONCASPAR 3 ZOLEDRONIC ACID 1 CALQUENCE LDD 3 ONIVYDE LDD 3 ZOLINZA 2 CAPECITABINE 1 OPDIVO LDD 3 ZYKADIA LDD 3 CAPRELSA LDD 3 PERJETA LDD 2 OSTEOPOROSIS COMETRIQ LDD 3 PHESGO LDD 2 FORTEO 2 COPIKTRA LDD 2 PIQRAY ^ 3 PROLIA 2 COTELLIC LDD 3 POMALYST LDD 3 RECLAST 3 CYRAMZA LDD 3 PORTRAZZA LDD 3 TYMLOS 2 DACOGEN 3 POTELIGEO LDD 3 ZOLEDRONIC ACID SOLUTION 1 DARZALEX LDD 3 PROLEUKIN 3 PAIN MANAGEMENT DECITABINE 1 PURIXAN LDD 3 PRIALT LDD 3 ELZONRIS LDD 3 REVLIMID LDD 2 QUTENZA LDD 3 EMPLICITI LDD 3 RITUXAN LDD 3 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA ERBITUX 3 RITUXAN HYCELA LDD 3 SOLIRIS LDD 3 ERIVEDGE LDD 2 ROMIDEPSIN 3 PHENYLKETONURIA ERLEADA LDD 2 ROZLYTREK LDD 3 KUVAN LDD 3 ERLOTINIB HYDROCHLORIDE 1 RUBRACA LDD 2 SAPROPTERIN DIHYDROCHLORIDE 1 ERWINAZE LDD 3 RYDAPT 2 PRE-TERM BIRTH EVEROLIMUS 1 SPRYCEL 2 HYDROXYPROGESTERONE CAPROATE 1 FOLOTYN 3 STIVARGA LDD 3 MAKENA LDD 3 FUSILEV 3 SUTENT LDD 2 PSORIASIS GAZYVA LDD 3 SYLATRON LDD 3 COSENTYX LDD 2 GILOTRIF LDD 3 SYLVANT LDD 3 COSENTYX SENSOREADY PEN LDD 2 HALAVEN 3 SYNRIBO LDD 3 HUMIRA PEN-PS/UV 2 HERCEPTIN LDD 3 TAFINLAR LDD 3 OTEZLA 2 HYCAMTIN 3 TAGRISSO LDD 3 SKYRIZI 2 IBRANCE LDD 2 TARCEVA LDD 3 STELARA SUBCUTANEOUS 2 ICLUSIG LDD 3 TARGRETIN 3 TALTZ LDD 2 IDHIFA LDD 3 TECARTUS LDD 3 TREMFYA 2 IMATINIB MESYLATE 1 TECENTRIQ LDD 3 IMBRUVICA LDD 3 TEMODAR 3 IMFINZI LDD 3 TEMOZOLOMIDE 1 IMLYGIC LDD 3 TEMSIROLIMUS 1 INLYTA LDD 3 TEPADINA 3

3 05.03.153.1B (04/2021) PULMONARY ARTERIAL HYPERTENSION RENAL DISEASE SLEEP DISORDER ADEMPAS LDD 2 CINACALCET HYDROCHLORIDE 1 HETLIOZ LDD 3 ALYQ 1 JYNARQUE LDD 3 XYREM LDD 3 AMBRISENTAN LDD 1 SENSIPAR 3 SYSTEMIC LUPUS ERYTHEMATOSUS BOSENTAN LDD 1 RESPIRATORY SYNCYTIAL VIRUS BENLYSTA LDD 3 EPOPROSTENOL SODIUM LDD 1 SYNAGIS LDD 3 THROMBOCYTOPENIA FLOLAN LDD 3 RHEUMATOID ARTHRITIS DOPTELET LDD 2 OPSUMIT LDD 2 ENBREL 2 MULPLETA 2 ORENITRAM LDD 2 ENBREL MINI 2 NPLATE 3 SILDENAFIL CITRATE 1 ENBREL SURECLICK 2 PROMACTA LDD 3 TADALAFIL 1 HUMIRA 2 TRANSPLANT TREPROSTINIL LDD 1 HUMIRA PEN 2 CYCLOSPORINE 1 TYVASO LDD 3 KEVZARA LDD 2 CYCLOSPORINE MODIFIED 1 UPTRAVI LDD 2 ORENCIA 2 EVEROLIMUS 1 VELETRI LDD 3 ORENCIA CLICKJECT 2 GENGRAF 1 VENTAVIS LDD 3 RASUVO 2 MYCOPHENOLATE MOFETIL 1 PULMONARY DISORDERS - OTHER RINVOQ 2 MYCOPHENOLIC ACID DR 1 ESBRIET LDD 2 SIMPONI ARIA 2 NEORAL 3 OFEV LDD 2 XELJANZ 2 NULOJIX 3 RARE DISORDERS - OTHER XELJANZ XR 2 PROGRAF 3 CRYSVITA LDD 3 SEIZURE DISORDERS SANDIMMUNE 3 FIRDAPSE LDD 3 ACTHAR LDD 3 SIROLIMUS 1 GAMIFANT LDD 3 DIACOMIT LDD 3 TACROLIMUS 1 LUXTURNA LDD 3 EPIDIOLEX LDD 3 UREA CYCLE DISORDERS RUZURGI LDD 3 FINTEPLA LDD 3 CARBAGLU LDD 3 SCENESSE LDD 3 VIGABATRIN LDD 1 SODIUM PHENYLBUTYRATE 1 SUCRAID LDD 3 VIGADRONE LDD 1 VENOUS INSUFFICIENCY ZOKINVY ^ LDD 3 SICKLE CELL DISEASE VARITHENA LDD 3 ADAKVEO 3 ENDARI LDD 3

Specialty medications may require prior authorization to ensure appropriate usage.

Coverage for these medications may vary with respect to your benefit design plan. We encourage you to refer to your plan documents for specialty drug coverage details. You’ll also learn more about the requirements and limitations of your pharmacy benefits and insurance plan.

To check coverage and copay information for a specific drug, please visit aetna.com and log in to your secure member website. If you don’t have access to our website, call the toll-free number on your member ID card.

This list is subject to change without notice to accommodate the introduction, removal and availability of new drugs and clinical information.

1: Generic Specialty; 2: Preferred Specialty; 3: Non-Preferred Specialty

LDD: Limited Distribution Product

^ New to list since last update

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