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 Arterial Hypertension Adempas riociguat Chronic Thromboembolic Pulmonary Hypertension/Pulmonary Arterial Hypertension Afinitor everolimus Oncology Alecensa alectinib Oncology Alferon interferon alfa-n3 Interferon Ampyra ER dalfampridine Multiple Sclerosis Aptivus tipranavir HIV/AIDS Apokyn apomorphine Parkinson's Disease Aranesp darbepoetin alfa Red Blood Cell Progenitor Arcalyst rilonacept Interleukin Blocker/CAPS Atripla efavirenz/emtricitabine/tenofovir HIV/AIDS Aubagio teriflunomide Multiple Sclerosis Avonex interferon beta-1a Multiple Sclerosis Baraclude entecavir Hepatitis B Berinert C1 esterase inhibitor Hereditary Angioedema Betaseron beta-interferon 1B Multiple Sclerosis Bethkis tobramycin for inhalation Cystic Fibrosis Bosulif bosutinib Oncology Buphenyl** sodium phenylbutyrate Nitrogen-Binding Agent Caprelsa vandetanib Oncology Carbaglu carglumic acid Endocrine Agent Cabometyx cabozantinib Oncology Cayston aztreonam lysine Cystic Fibrosis

*generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 Cetrotide cetrorelix Specialized OB/GYN Chemet succimer Chelating Agent Chenodal chenodiol Gallstone Solubilizing Agent 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 Cotellic cobimetinib fumarate Oncology Cuprimine** penicillamine Wilson’s Disease/Cystinuria/ Rheumatoid Arthritis Cystadane betaine Homocystinuria Cystaran cysteamine Cystine-Depleting Agent Daklinza daclatasvir dihydrochloride Hepatitis C Daraprim** pyrimethamine Antimalarial DDAVP nasal desmopressin* Vasopressin Analogue spray/rhinal tube Demser** metyrosine Pheochromocytoma

Depen** penicillamine Wilson’s disease/Cystinuria/ Rheumatoid Arthritis Descovy emtricitabine/tenofovir HIV/AIDS Edurant rilpivirine HIV/AIDS Engraft tesamorelin Growth Hormone Emtriva emtricitabine HIV/AIDS Enbrel etanercept Anti-Tumor Necrosis Factor Drug/ Arthritis/Psoriasis Epclusa sofosbuvir/velpatasvir Hepatitis C Epivir lamivudine* HIV/AIDS Epivir-HBV lamivudine* Hepatitis B Epogen epoetin alfa Red Blood Cell Progenitor Epzicom abacavir/lamivudine HIV/AIDS Erbitux cetuximab Oncology Erivedge vismodegib Oncology Erwinaze asparaginase Oncology Exjade deferasirox Chelating Agent Extavia interferon beta-1b Interferon Farydak panobinostat Oncology

*generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification Ferriprox deferiprone Iron Overload Fertinex urofollitropin Ovulatory Stimulant Firazyr icatibant Hereditary Angioedema Follistim AQ follitropin beta Ovulatory Stimulant Forteo teriparatide Parathyroid Hormone for Osteoporosis/Bones Fulyzaq crofelemer HIV/AIDS Fuzeon enfuvirtide HIV/AIDS Ganirelix gonadotropin-releasing hormone Specialized OB/GYN antagonist Gattex glucagon-like peptide 2 analog Gastrointestinal Genotropin somatropin Growth Hormone Genvoya elvitegravir/cobicistat/emtricitabine HIV/AIDS /tenofovir alafenamide fumarate Gleevec imatinib Oncology Gilenya fingolimod Multiple Sclerosis Gilotrif afatinib Oncology Gleostine lomustine Oncology Gonal-F follitropin alfa Ovulatory Stimulant Gonal-F RFF follitropin alfa Ovulatory Stimulant 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 Humira adalimumab Monoclonal Antibody/Arthritis/ Psoriasis/Crohns/Ankylosing Spondylitis Ibrance palbociclib Oncology Iclusig ponatinib Oncology Imbruvica ibrutinib Oncology Impavido miltefosine Antileishmanial Ilaris canakinumab Interleukin Blocker Incivek telaprevir Hepatitis C Increlex mecasermin Growth Hormone Infergen interferon alfacon-1 Interferon Intelence etravirine HIV/AIDS Intron-A interferon alfa-2b Interferon Invirase saquinavir HIV/AIDS Iressa getfitinib Oncology *generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification Isentress raltegravir HIV/AIDS Jakafi ruxolitinib Oncology Juxtapid lomitapide Hypercholesterolemia Kaletra lopinavir/ritonavir HIV/AIDS Kalydeco ivacaftor Respiratory Keveyis dichlorphenamide Carbonic Anhydrase Inhibitor Kineret anakinra Immunologic Agent Korlym mifepristone Endocrine/Cushing’s Disease Kuvan sapropterin dihydrochloride Phenylketonuria Kynamro mipomersen Hypercholesterolemia Lenvima lenvatinib Oncology Letairis ambrisentan Pulmonary Arterial Hypertension

leucovorin leucovorin* Folinic Acid for Anemia Lexiva amprenavir HIV/AIDS Lithostat** acetohydroxamic acid Urinary Acidifier Lomustine lomustine Oncology Lonsurf trifluridine/tipiracil HCl Oncology Lupron leuprolide Gonadotropin-Releasing Hormone (all products) Analog Luveris lutropin alfa Ovulatory Stimulant Lynparza olaparib Oncology Lysodren mitotane Oncology Makena hydroxyprogesterone Hormone Matulane procarbazine Oncology Mekinist trametinib Oncology Menopur menotropins Ovulatory Stimulant Mestinon syrup** pyridostigmine Antimyasthenic Moderiba ribavirin* Antiviral for Hepatitis C Myalept metreleptin Leptin Analog Myleran busulfan Oncology Mytesi crofelemer HIV/AIDS Natpara parathyroid hormone Hypoparathyroidism Neumega oprelvekin Interleukin for platelets Neupogen filgrastim Colony Stimulating Factor for Use with Chemotherapy Nexavar sorafenib Oncology Nilandron nilutamide Oncology Ninlaro ixazomib Oncology

*generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification Norditropin (all somatropin Growth Hormone products) Northera droxidopa Neurogenic Orthostatic Hypotension Norvir ritonavir HIV/AIDS Novarel human chorionic gonadotropin Specialized OB/GYN Nuedexta** dextromethorphan hydrobromide Pseudobulbar Affect /quinidine sulfate Nuplazid pimavenserin Antipsychotic – SSIA Nutropin (all somatropin Growth Hormone products) Ocaliva obeticholic acid Primary Biliary Cholangitis Odefsey emtricitabine/rilpivirine/tenofovir HIV/AIDS Odomzo sonidegib phosphate Oncology Olysio simeprevir Hepatitis C Omnitrope somatropin Growth Hormone Opsumit macitentan Pulmonary Arterial Hypertension Orencia/Clickject abatacept Selective Co-Stimulation Modulator for RA Orenitram treprostinil Pulmonary Arterial Hypertension Orfadin nitisinone Tyrosinemia Type 1 Otezla apremilast Psoriatic Arthritis Otrexup** methotrexate Arthritis/Polyarticular Juvenile Idiopathic Arthritis/Psoriasis Ovidrel choriogonadotropin alfa Specialized OB/GYN Oxsoralen methoxsalen Psoralen Oxsoralen-Ultra methoxsalen Psoralen Panretin alitretinoin (gel) HIV/AIDS Pegasys peginterferon alfa-2a Hepatitis C Peg-Intron peginterferon alfa-2b Hepatitis C Plegridy peginterferon beta-1a Multiple Sclerosis Pomalyst pomalidomide Oncology Praluent alirocumab PCSK-9 Inhibitor Pregnyl chorionic gonadotropin Specialized OB/GYN Prezista darunavir HIV/AIDS Procrit epoetin alfa Red Blood Cell Progenitor Profasi chorionic gonadotropin Specialized OB/GYN Proglycem** diazoxide Hypoglycemia Promacta eltrombopag olamine Thrombopoietic Agent Pulmozyme dornase alfa Cystic Fibrosis Qutenza capsaicin Postherpetic Neuralgia *generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification 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 evolocumab PCSK-9 Inhibitor Rescriptor delavirdine HIV/AIDS Retrovir zidovudine* HIV/AIDS Revatio sildenafil* Pulmonary Arterial Hypertension Revlimid lenalidomide Oncology Reyataz atazanavir HIV/AIDS Ribapak ribavirin* Antiviral for Hepatitis C ribasphere ribavirin* Antiviral for Hepatitis C Ribatab ribavirin* Antiviral for Hepatitis C Rilutek riluzole* Sclerosis Roferon-A interferon alfa-2a recombinant Interferon Sabril vigabatrin Anticonvulsant Saizen somatropin Growth Hormone Sandostatin octreotide Acromegaly/Carcinoid Syndrome/ VIPomas Selzentry maraviroc HIV/AIDS Serostim somatropin HIV/AIDS Signifor pasireotide Somatostatin/Cushing’s Disease Simponi golimumab Anti-Tumor Necrosis Factor Drug Sirturo bedaquiline Tuberculosis Somavert pegvisomant Acromegaly Sovaldi sofosbuvir Hepatitis C Sprycel dasatinib Oncology Stelara ustekinumab Interleukin Blocker Stimate nasal desmopressin Vasopressin Analogue spray Stivarga regorafenib Oncology Strensiq asfotase alfa Hypophosphatasia Stribild elvitegravir/cobicistat/emtricitabine HIV/AIDS /tenofovir Sucraid sacrosidase Enzyme Replacement Sustiva efavirenz HIV/AIDS Sutent sunitinib Oncology Sylatron peginterferon alfa-2b Oncology Synarel** nafarelin acetate Gonadotropin-Releasing Hormone Analog *generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification Synribo omacetaxine Oncology Syprine** trientine Wilson’s Disease Tafinlar dabrafenib Oncology Tagrisso osimertinib Oncology Taltz ixekizumab Monoclonal Antibody Tarceva erlotinib Oncology Targretin (all bexarotene Oncology products) Tasigna nilotinib Oncology Tecfidera dimethyl fumarate Multiple Sclerosis Technivie ombitasvir/paritaprevir/ritonavir Hepatitis C Temodar temozolomide Oncology Tev-Tropin somatropin Growth Hormone Thalomid thalidomide Oncology Thiola** tiopronin Kidney Stone Agent Tivicay dolutegravir HIV/AIDS Tobi/Tobi Podhaler tobramycin for inhalation Cystic Fibrosis Tracleer bosentan Pulmonary Arterial Hypertension Triumeq dolutegravir/abacavir/lamivudine HIV/AIDS Trizivir abacavir/lamivudine/zidovudine HIV/AIDS Truvada emtricitabine/tenofovir HIV/AIDS Tybost cobicistat HIV/AIDS Tykerb lapatinib Oncology Tysabri natalizumab Monoclonal Antibody/Multiple Sclerosis Tyvaso treprostinil Pulmonary Arterial Hypertension Tyzeka telbivudine Hepatitis B Uptravi selexipag Pulmonary Arterial Hypertension Valchlor mechlorethamine Oncology Veltassa patiromer Hyperkalemia Vandetanib vandetanib Oncology Vecamyl mecamylamine Hypertension Venclexta venetoclax Oncology Ventavis iloprost Pulmonary Arterial Hypertension VePesid etoposide Oncology Versacloz clozapine Antipsychotic Victrelis boceprevir Hepatitis C ombitasvir/paritaprevir/ritonavir/ Viekira Pak/XR Hepatitis C dasabuvir Videx/EC didanosine* HIV/AIDS

*generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8 Brand Name Generic Name Drug Classification Viracept nelfinavir HIV/AIDS Viramune nevirapine* HIV/AIDS Viread tenofovir HIV/AIDS Vistogard uridine triacetate granule Reversal Agent Votrient pazopanib Oncology Xalkori crizotinib Oncology Xeljanz/XR tofacitinib Immunologic Agent Xeloda capecitabine Oncology Xenazine tetrabenazine Huntington’s Disease Xtandi enzalutamide Oncology Xuriden uridine triacetate granule Hereditary Orotic Aciduria Xyrem gamma hydroxybutyrate Cataplexy Zavesca miglustat Gaucher’s Disease Zecuity sumatriptan succinate Anti-Migraine Zelboraf vemurafenib Oncology Zepatier elbasvir/grazoprevir Hepatitis C Zerit stavudine* HIV/AIDS Ziagen abacavir* HIV/AIDS Zinbryta daclizumab Monoclonal Antibody Zolinza vorinostat Oncology Zorbtive somatropin Growth Hormone Zykadia ceritinib Oncology Zydelig Idelaisib Oncology Zytiga abiraterone acetate Oncology

*generic drug is not included in the Specialty Pharmacy Program as of January 1, 2016. **Addition to Specialty list effective as of January 1, 2017 04HQ3922 R10/16 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 8