Pharmacy | Specialty Medication Cost Share Drug List | May 1, 2021

Specialty medication cost share drug list by therapeutic class

This list contains specialty medications included in the Specialty Medication Cost Share1 (SMCS) drug list and is updated three times per year. This list applies to large group SMCS plans on the July 2021 rider and later and small group SMCS plans on the January 2022 rider and later. For the most up-to-date drug coverage information, please call Customer Care at the toll-free member phone number on your health plan ID card; or log in to myuhc.com® to learn more about your pharmacy benefit and medication pricing.

Therapeutic Drug Name Therapeutic Drug Name Therapeutic Drug Name Class Class Class Anemia Aranesp SL Cancer Cotellic PA SL Cancer Leuprolide PA Epogen SL E continued Daurismo PA SL continued Lonsurf PA SL Procrit SL E Eligard PA Lorbrena PA Retacrit SL Erivedge PA SL Lynparza PA SL Asthma Fasenra PA SL Erleada PA SL Matulane Nucala PA SL Erlotinib PA SL Mekinist PA SL Cancer Abiraterone 250mg Etoposide Mektovi PA SL ST PA SL Everolimus PA SL Melphalan Abiraterone 500mg Farydak PA SL Mesnex PA SL E Gilotrif PA SL Nerlynx PA SL Afinitor 10 mg PA SL Gleevec PA SL E Nexavar PA SL Afinitor Dis PA SL Gleostine Nilandron Afinitor 2.5 mg, 5 mg, Hycamtin PA SL Nilutamide 7.5 mg PA E Ibrance PA SL Ninlaro PA SL Alecensa PA SL Iclusig PA SL Nubeqa PA SL Alkeran Idhifa PA SL Odomzo PA SL Alunbrig PA SL Imatinib PA SL Onureg PA SL Ayvakit PA SL Imbruvica PA SL Pemazyre PA SL Balversa PA SL Inlyta PA SL Piqray PA SL Bexarotene E Inqovi PA SL Pomalyst PA SL Bosulif PA SL ST Inrebic PA SL ST Purixan PA Braftovi PA SL ST Intron A PA Qinlock PA SL Brukinsa PA SL Iressa PA SL Retevmo PA SL Cabometyx PA SL Jakafi PA SL Revlimid PA SL Calquence PA SL Kisqali PA SL ST Rozlytrek PA SL Capecitabine SL Koselugo PA SL Rubraca PA SL ST Caprelsa PA SL Lapatinib PA SL Rydapt PA SL Cometriq PA SL Lenvima PA SL Sprycel PA SL ST Copiktra PA SL Bold = Brand Drug Name E – May be excluded from coverage PA – Notification/Prior Authorization required* SL – Supply Limit ST – Step Therapy continued Therapeutic Drug Name Therapeutic Drug Name Therapeutic Drug Name Class Class Class Cancer Stivarga PA SL CNS Agents Hetlioz PA SL Endocrine Octreotide PA continued Sutent PA SL continued Hetlioz LQ PA SL E continued Penicillamine Sylatron PA SL Ingrezza PA SL ST Procysbi PA ST Synribo PA SL Rilutek Ravicti PA SL ST Tabloid Riluzole Samsca PA SL Tabrecta PA SL Ruzurgi PA SL Sandostatin PA E Tafinlar PA SL Sabril Powder Pack Sapropterin PA SL Tagrisso PA SL PA SL E Signifor PA SL Talzenna PA SL ST Sabril Tablets PA SL Sodium Phenylbutyrate Tarceva PA SL E Tetrabenazine PA PA Targretin Capsules Tiglutik PA Somatuline Depot Targretin Gel SL Vigabatrin PA SL Somavert PA SL Tasigna PA SL ST Vigadrone PA SL Syprine PA E Tazverik PA SL Xenazine PA E Thiola Temodar PA E Cystic Fibrosis Bethkis PA SL E Thiola EC Temozolomide PA Cayston PA ST Tolvaptan PA SL Tepmetko PA SL E Kalydeco PA SL Trientine PA Thalomid PA SL Kitabis Pak PA SL E Xermelo PA SL Tibsovo PA SL Orkambi PA SL Xuriden PA SL Tretinoin Capsules SL Pulmozyme PA SL Enzyme Cerdelga PA Tukysa PA SL Symdeko PA SL Deficiency Cholbam PA SL Turalio PA SL TOBI Nebulized Cystagon Tykerb PA SL Solution PA SL E Galafold PA SL Ukoniq PA SL E TOBI Podhaler PA SL Miglustat Valchlor PA SL Tobramycin Nebulized Nitisinone PA E Venclexta PA SL Solution 300 mg/4 mL Nityr PA E Verzenio PA SL PA SL Orfadin PA Vitrakvi PA SL Tobramycin Nebulized Palynziq PA SL Vizimpro PA SL Solution 300 mg/5mL Strensiq PA SL Votrient PA SL PA SL E Sucraid PA Trikafta PA SL Xalkori PA SL Tegsedi PA SL Endocrine Buphenyl PA Xeloda SL E Zavesca E Bynfezia Pen PA E Xospata PA SL Genetic Dojolvi PA Carbaglu PA Xpovio PA SL Disorder Chenodal Xtandi PA SL ST Growth Genotropin PA E Clovique PA E † Yonsa PA SL ST E Hormone Humatrope PA E Cuprimine E Zejula PA SL Increlex PA SL Cystadane Zelboraf PA SL Norditropin PA E Depen Titratabs Zolinza PA SL Nutropin AQ PA SL Egrifta PA Zydelig PA SL Omnitrope PA E Firmagon Zykadia PA SL Saizen PA E Gattex PA SL Zytiga PA SL E Serostim PA SL Cardiovascular Droxidopa PA SL H.P. Acthar PA SL ST Zomacton PA E Northera PA SL E Isturisa PA SL Zorbtive PA SL Vyndamax PA SL Jynarque PA SL Hematologic Cablivi PA SL Vyndaqel PA SL Keveyis PA SL Doptelet PA SL ST Cholesterol/ Juxtapid PA SL ST Korlym PA Mozobil PA SL E Lipid Lowering Kuvan Mulpleta PA SL CNS Agents Austedo PA SL Myalept PA SL Oxbryta PA SL Enspryng PA SL Mycapssa PA SL E Promacta PA Firdapse PA SL ST E Natpara PA SL Tavalisse PA SL ST

continued Therapeutic Drug Name Therapeutic Drug Name Therapeutic Drug Name Class Class Class Hemophilia Advate Hepatitis C Sofosbuvir/ Inflammatory Tremfya PA SL Adynovate PA continued Velpatasvir PA SL Conditions Xeljanz PA SL ST Afstyla PA Sovaldi PA SL ST continued Xeljanz XR PA SL ST Alphanate Viekira Pak PA SL ST Iron Overload Deferasirox PA Alphanine SD Vosevi PA SL Deferiprone PA Alprolix Zepatier PA SL Exjade PA E Benefix Hereditary Berinert PA SL ST Ferriprox PA Coagadex Angioedema Cinryze PA SL E Jadenu PA E Corifact Firazyr PA SL Jadenu Sprinkle PA E Eloctate PA Haegarda PA SL Liver Disease Ocaliva PA SL ST Esperoct PA ST E Icatibant PA SL E Lupus Benlysta PA SL Feiba Ruconest PA SL Mental Health Spravato PA SL Helixate FS PA E Takhzyro PA SL Multiple Ampyra PA SL E Hemlibra PA Immune Actimmune PA SL Sclerosis Aubagio PA SL Hemofil M Modulator Arcalyst PA SL Avonex PA SL Humate-P Immunotherapy Palforzia PA SL Bafiertam PA SL Idelvion Infections Arikayce PA SL Betaseron PA SL Ixinity PA ST E Daraprim PA Copaxone PA SL E Jivi PA Pyrimethamine PA Dalfampridine PA SL Koate Infertility† Cetrotide PA ST SL Dimethyl Fumarate PA Koate-DVI Chorionic SL Kogenate FS Gonadotropin Extavia PA SL ST E Kovaltry Follistim AQ Gilenya PA SL Mononine Ganirelix Acetate Glatiramer PA SL Novoeight Gonal-F ST Glatopa PA SL Novoseven RT Gonal-F RFF ST Kesimpta PA SL Nuwiq Menopur Mavenclad PA SL ST Profilnine Novarel Mayzent PA SL Rebinyn E Ovidrel Plegridy PA SL Recombinate Pregnyl Rebif PA SL ST Rixubis Inflammatory Actemra PA SL ST Tecfidera PA SL ST E SevenFACT E Conditions Cimzia PA SL Vumerity PA SL ST E Tretten Cosentyx PA SL ST Zeposia PA SL Vonvendi Dupixent PA SL ST Narcolepsy Wakix PA SL Wilate Emflaza PA ST E Xyrem PA SL Xyntha PA ST Enbrel PA SL ST Xywav PA SL Hepatitis B Adefovir Humira PA SL Neutropenia Fulphila E Baraclude Solution Ilumya PA SL ST E Granix E Baraclude Tablets E Kevzara PA SL ST Leukine Entecavir Kineret PA SL Neulasta Epivir HBV Olumiant PA SL Neupogen E Hepsera Orencia PA SL ST Nivestym E Lamivudine Otezla PA SL Udenyca E Vemlidy ST Ridaura Zarxio Hepatitis C Epclusa PA SL Rinvoq PA SL Ziextenzo Harvoni Tab PA SL ST Siliq PA SL ST E Ophthalmic Cystadrops PA SL Ledipasvir/Sofosbuvir Simponi PA SL Agents Cystaran PA SL PA SL ST Skyrizi PA SL Oxervate PA SL Mavyret PA SL Stelara PA SL Osteoporosis Forteo PA ST E Pegasys PA SL Taltz PA SL ST E Teriparatide PA Pegintron PA SL Tymlos PA

continued Therapeutic Drug Name Therapeutic Drug Name Therapeutic Drug Name Class Class Class Parkinson’s Apokyn PA SL Spinal Evrysdi PA SL Transplant Sandimmune Disease Inbrija PA SL Muscular continued Capsules E Kynmobi PA SL Atrophy Sirolimus Pulmonary Esbriet PA SL Transplant Astagraf XL E Tacrolimus Fibrosis Ofev PA SL Cellcept E Zortress E Pulmonary Adcirca PA SL E Cyclosporine Hypertension Adempas PA SL Envarsus XR E Alyq PA SL Everolimus Ambrisentan PA SL Gengraf Bosentan PA SL Mycophenolate Letairis PA SL E Suspension Mycophenolate Opsumit PA SL Capsules Orenitram PA SL Mycophenolate Revatio SL E Delayed-released Sildenafil Suspension Tablet PA SL Myfortic E Sildenafil Tablets SL Neoral E Tadalafil PA SL Prograf Tracleer PA SL Prograf Granules for Tyvaso PA Suspension PA Uptravi PA SL Rapamune Ventavis PA Oral Solution Seizures Diacomit PA Rapamune Tablets E Epidiolex PA Sandimmune Fintepla PA Oral Solution

This list is intended to be general and is subject to variation due to state law or mandate. Drugs may be added or removed. Please refer to your benefit plan materials provided by your employer or health plan to determine which medications may be covered or limited under your plan. * Depending on your benefit, you may have notification or prior authorization requirements for select medications. Your doctor is required to provide additional information to us to determine coverage. † Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans or where a state mandates infertility drug coverage. CALIFORNIA HMO ONLY: For California HMO plans, certain injectable drugs are covered under the medical benefit. To understand your specific coverage for injectable and other specialty medications, please review the PDL booklet on myuhc.com, or call Customer Service at the number on the back of your card. Not all plan designs cover all listed medications. Please refer to your benefit plan materials provided by your employer or health plan to determine which medications may be covered under your plan and to determine coverage limitations. Medications may also require sourcing through a Designated Specialty Pharmacy. Some medications are noted with the symbols below. Your benefit plan determines how these medications may be covered for you. All branded medications are trademarks or registered trademarks of their respective owners. This list does not apply to SignatureValue business administered by OptumRx®. B2C 4/21 ©2021 United HealthCare Services, Inc. WF4172259