Current Specialty Medication List (as of 1/1/2020)

[Pages:5]Current Specialty Medication List (as of 07/01/2022)

New Drug Additions in Red

8-Mop Abecma Abraxane Abilify Maintena Abrilada Accrufer Actemra SOC ACTHAR Actimmune Adakveo SOC Adbry Adcirca Adecetris Adefovir Adempas Adriamycin Adrucil Aduhelm Advate Advate H Advate L Advate M Advate SH Advate UH Adynovate Afinitor Afinitor Disperz Afstyla Aldurazyme Alecensa Alferon N Alimta Aliqopa ALKERAN Alphanate Alphanine SD Alprolix Alunbrig Amondys 45 Ampyra Andexxa Anjeso Apokyn Apomorphine Hydrochloride Apretude

Aralast ARANESP / SURECLICK ARCALYST Aredia Arestin Arikayce Kit Aristada Aristada Initio Arranon Arzerra Asceniv Asparlas Astagraf XL Atgam Aubagio Austedo Avastin Avonex Avsola Ayvakit Bafiertam Balversa Baraclude Bavencio BCG Vaccine

(Tice Strain) Bebulin VH Immuno Beleodaq Belrapzo Bendeka Benefix Benlysta SOC Beovu Berinert SOC Besponsa Besremi Betaine Anhydrous Betaseron Bethkis Bicnu Bivigam SOC Blenoxane Blenrep Blincyto Bortezomib Bosulif

Botox Braftovi Breyanzi Brineura Bronchitol Brukinsa Buphenyl Busulfex Bylvay Bynfezia Pen Byooviz Cablivi Calcijex Calquence Camcevi Campath Camptosar Camzyos Capecitabine Caprelsa Carbaglu Carbometyx Carimune NF SOC Carvykti CAYSTON Ceenu Cellcept Ceprotin Cerdelga Cerezyme Cerubidine Chirhostim Cibinqo Cimzia SOC Cinqair SOC Cinryze SOC Clolar Clovique Coagadex Cometriq Copaxone Copegus Copiktra Cortifact Cosela Cosentyx

Cosmegen Cotellic Crysvita SOC Cuprimine Cutaquig Cuvitru Cyklokapron Cyltezo Cyramza Cystadane Cystadrops Cystaran Cytarabine Cytogam CYTOXAN Dacogen Daklinza Danyelza Darzalex Darzalex Faspro Daurismo Depen Depo Provera Depocyt Desferal Dexferrum Diacomit Dojolvi Doptelet Doxil Doxorubicin Doxorubicin Liposomal Droxia Droxidopa Dupixent Durolane Durysta Dysport Elaprase Elelyso ELIGARD Elitek Ellence Eloctate Eloxatin Elzonris

*The list of drugs contained on this specialty list, or subject to Site of Care requirements is subject to change. **If you have questions about which medication your specific plan covers please refer to your benefits book or check BCBSNC formulary

webpage at . If you need to speak with someone please call the customer service number on the back of your card.

? Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Current Specialty Medication List (as of 07/01/2022)

New Drug Additions in Red

Emcyt Emflaza Empaveli Empliciti Enbrel Endari Enhertu Entecarvir Entyvio SOC Envarsus XR Epclusa Epidiolex EPOGEN Erbitux Erivedge Erleada Erwinaze Esbriet Esperoct Ethyol Eticovo ETOPOPHOS Euflexxa Eulexin Evenity SOC Evkeeza Exjade Exkivity Exondys 51 Exservan Extavia Evomela Evrysdi Eylea Fabrazyme Farydak Fasenra SOC FASLODEX Feiba Fensolvi Feraheme Ferriprox Ferrlecit Fibryna Fintepla FIRAZYR SOC

Firdapse

Hemlibra

Firmagon

Hemofil M

Flebogamma SOC

Hepsera

Flolan

Herceptin

Fludara

Herceptin Hylectra

Folotyn

Hetlioz

Forteo

Hexalen

Foscavir

Hizentra SOC

Fotivda

Hulio

Fudr

Humate-P

fulphila

Humatrope

Fusilev

Humira

Fyarro

Hyalgan

Galafold

HYCAMTIN

Gamifant

Hydrea

Gammagard SOC

Hylenex

Gammagard S/D SOC Hymovis

Gammaked SOC

Hyperrho S-D

Gammaplex SOC

Hyqvia SOC

Gamunex SOC

Hyrimoz

Gamunex-C SOC

Ibalizumab

Gastrocrom

Ibrance

Gattex

Ibrutinib

Gavreto

Iclusig

Gazyva

Idamycin PFS

Gel-One

Idelvion

Gelsyn 3

Idhifa

Gemzar

Ifex

Gengraf

Ilaris SOC

Genotropin

ILUMYA SOC

Genotropin Miniquick Imatinib

GenVisc 850

Imbruvica

GILENYA

Imcivree

Gilotrif

Imfinzi

Givlaari SOC

Imlygic

Glassia SOC

Implanon

Glatopa

Increlex

Gleevec

Infed

Gloestine

Infergen

Granix

Inflectra SOC

Hadlima

Infugem

Haegarda

Ingrezza

Halaven

Injectafer

Harvoni

Inlyta

Hecoria

Inqovi

Helixate FS

Inrebic

Invega Sustenna Invega Trinza Iressa Istodax Isturisa Ixempra Ixinity Jadenu Jakafi Jelmyto Jemperli Jetrea Jeuveau Jevtana Jivi Juxtapid Jynarque Kadcyla Kalbitor SOC Kalydeco Kanjinti Kanuma Kepivance Kesimpta Keveyis Kevzara Keytruda Khapzory Kimmtrak Kineret Kisqali Kisqali-Femara KITABIS PAK Koate-DVI Kogenate FS / Kogenate-FS Bio-Set Korlym Koselugo Kovaltry KRYSTEXXA Kuvan Kynamro Kyleena Kymriah Kyprolis

LANREOTIDE SOC

*The list of drugs contained on this specialty list, or subject to Site of Care requirements is subject to change. **If you have questions about which medication your specific plan covers please refer to your benefits book or check BCBSNC formulary

webpage at . If you need to speak with someone please call the customer service number on the back of your card.

? Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Current Specialty Medication List (as of 07/01/2022)

New Drug Additions in Red

Lemtrada SOC Lenalidomide Lenvima Leqvio Letairis Leukeran LEUKINE Leustatin Libtayo Liletta Lipodox Livmarli Livtencity Lonsurf Lorbrena Lucentis Lumakras Lumizyme Lumoxiti Lupknis LUPRON DEPOT Lutathera Luxturna Lynparza Lysodren Macugen Makena Margenza Marqibo Matulane Mavenclad Mavyret Mayzent Mekinist Mektovi Melphalan Mepsevii Mesnex Micrhogam Micrhogam Plus MIRCERA Mirena Mitomycin Monjuvi Monoclate-P Mononine

Monovisc MOZOBIL Mulpleta Mustargen Mvasi MYALEPT Mycapssa Myfortic Myleran Mylotarg Myobloc Naglazyme Natpara Navelbine Neoral Nerlynx NEULASTA Neumega NEUPOGEN Nexavar Nexplanon Nexviazyme Nilutamide Ninlaro Nipent nivestym Norditropin Norditropin Flexpro Northera Novantrone Novoeight Novoseven/RT NPLATE SOC Nubeqa Nucala SOC Nulibry Nulojix Nutropin Nutropin AQ Nuwiq Nyvepria Obizur Ocaliva Ocrevus SOC Octagam SOC Odomzo

Ofev Oforta Ogivri Olysio Olumiant Omnitrope Oncaspar Onivyde Onpattro SOC Onureg Onxol Opdivo Opdualag Opsumit Orencia SOC Orenitram Orfadin Orgovyx Orkambi Orladeyo Orthovisc Otezla Oxbryta Oxlumo SOC Paclitaxel Protein Bound Particles Padcev Palforzia Palynziq Panretin Panzyga Paraguard IUD Paraplatin Parsabiv Pegasys Pemazyre Pemfexy Perjeta Perseris Phesgo Photofrin Piqray Pirfenidone Platinol AQ Plegridy Polivy

Pomalyst Ponvory Portrazza Poteligeo Prevymis Prialt Privigen SOC PROCRIT Procysbi Profilnine SD Prograf Prolastin-C SOC Proleukin Prolia Promacta Provenge Pulmozyme Purixan Pyrukynd Qutenza Radicava SOC Rapamune Ravicti Rayaldee Rebetol Rebif Reblozyl SOC Reclast Recombinate Recorlev RELEUKO Remicade SOC Remodulin Renflexis SOC Resperidal Consta

RETACRIT

Rethymic Retisert Revatio Revcovi Revlimid Rezurock Rhogam-UF Plus Rhophylac Riabni Riastap

*The list of drugs contained on this specialty list, or subject to Site of Care requirements is subject to change. **If you have questions about which medication your specific plan covers please refer to your benefits book or check BCBSNC formulary

webpage at . If you need to speak with someone please call the customer service number on the back of your card.

? Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Current Specialty Medication List (as of 07/01/2022)

New Drug Additions in Red

Ribavirin Rilutek Rinvoq Rituxan Rituxan Hycela Rixubis Romidepsin Rozlytrek Rubraca Ruconest SOC Ruxience Rybrevant Rydapt Rylaze Ryplazim Sabril Saizen Samsca SANDIMMUNE SANDOSTATIN SOC SANDOSTATIN LAR SOC Saphnelo Sarclisa Scenesse Sensipar Serostim Sevenfact SIGNIFOR Signifor LAR SOC Siklos Siliq Simponi Simponi Aria SOC Simulect Sirolimus Sirturo Skyla IUD Skyrizi Skytrofa Sogroya Soliris SOC SOMATULINE DEPOT SOC Somavert Sovaldi Spinraza Spravato

Sprycel Spyrine STELARA SOC Stimate Stivarga Strensiq Sublocade Sucraid Supartz Supprelin LA Susvimo Sutent SYLATRON Sylvant Symdeko Synagis Synarel Synojoynt Synribo Synvisc Synvisc One Syprine Tabloid Tabrecta Tafinlar Tagrisso Takhzyro Taltz Talzenna Tarceva Targretin Tarpeyo Tascenso Odt Tasigna Tavalisse Taxol Taxotere Tazverik Tecartus Tecentriq Tecfidera Tegsedi TEMODAR Tepadina Tepezza SOC Tepmitko

Tev-Tropin Tezspire Thalomid Theracys Thiola Thiola EC Thymoglobulin THYROGEN Tiglutik Kit Tivdak Tobi Tobi Podhaler Toposar Torisel Totect Tracleer Trazimera Treanda Trelstar Depot, LA,

Mixject TREMFYA SOC Tretten Trikafta Triluron Triptodur Trisenox Trivisc Trodelvy Trogarzo SOC Truseltiq Truxima Tukysa Tykerb Tymlos Tysabri SOC Tyvaso UDENYCA Ukoniq Ultomiris SOC Unituxin Uplinza SOC Uptravi Vabysmo Valchlor Valstar Vantas

Vectibix Velban Velcade Veletri Vemlidy Venclexta Venofer Ventavis Verenzio Vesanoid VICTRELIS VIDAZA Viekira Pak Viekira XR Vijoice Viltepso Vimizim Vincasar Virazole Visco-3 Vistogard Visudyne Vitrakvi Vitrase Vivitrol Vizimpro Vonjo Vonvendi Vosevi Votrient Voxzogo VPRIV Vumerity Vumon Vyepti SOC Vyndamax Vyndaqel Vyondys 53 Vyvgart Vyxeos Wakix Welireg Wilate Winrho SDF Xalkori Xaracoll

*The list of drugs contained on this specialty list, or subject to Site of Care requirements is subject to change. **If you have questions about which medication your specific plan covers please refer to your benefits book or check BCBSNC formulary

webpage at . If you need to speak with someone please call the customer service number on the back of your card.

? Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

Xeljanz Xeloda Xembify Xenazine Xenleta Xeomin Xermelo Xgeva Xiaflex Xolair SOC Xospata Xpovio Xtandi Xuriden Xyntha

Current Specialty Medication List (as of 07/01/2022)

New Drug Additions in Red

Xyrem Xywav Yervoy Yescarta Yondelis Yonsa Yusimry Yutiq Zaltrap Zanosar ZARXIO ZAVESCA Zecuity Zejula Zelboraf

Zemaira Zepatier Zeposia Zelzelca Ziextenzo Zinecard Zinplava Zirabev Zokinvy Zoladex Zolgensma Zolinza Zomacton Zometa Zorbtive

Zortress Ztalmy Zulresso Zydelig Zykadia Zynbryta Zynlonta Zytiga

Bolded ? self-administered ? these drugs may be administered by the patient themselves. For most members these drugs are covered by the pharmacy benefit and must be obtained by a participating specialty pharmacy provider.

Non-bolded ? provider-administered ? these drugs are administered by a medical provider. For most members these drugs are covered under their medical benefit

CAPITAL ? can be self administered or provider administered

SOC ? Site of Care: Member must meet BCBSNC clinical criteria and receive plan approval to receive drug in an outpatient hospital setting

*The list of drugs contained on this specialty list, or subject to Site of Care requirements is subject to change. **If you have questions about which medication your specific plan covers please refer to your benefits book or check BCBSNC formulary

webpage at . If you need to speak with someone please call the customer service number on the back of your card.

? Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

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