FEP Specialty Pharmacy Drug List Form

*Prior Authorization required

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Last Revised 05-01-2026 Service Benefit Plan Specialty Pharmacy Drug List

If you are a member or healthcare provider and have specialty drug-specific questions, please call the Specialty Pharmacy Program at 1- 888-346-3731 weekdays from 7 a.m. to 9 p.m. or weekends from 8 a.m. to 6:30 p.m. Eastern time. You can also visit fepblue.org/pharmacy.

Specialty drugs are prescribed to treat complex conditions such as multiple sclerosis, hemophilia, hepatitis C and rheumatoid arthritis. These drugs also have one or more of the following traits: they are injected or infused (but some may be taken by mouth); they have unique storage or shipment needs; more education and support are needed to help you use the drugs properly, and they are usually not stocked at retail pharmacies.

                            The list below only applies to drugs processed through the pharmacy benefit.

The Blue Cross and Blue Shield Service Benefit Plan maintains a list of specialty prescription drugs. Coverage of and out- of- pocket costs for drugs on this list may be different under Standard Option, Basic Option, and FEP Blue Focus. Please select your plan, using the Drug Cost Tool, to confirm your coverage and cost information. This is not an all-inclusive list and is subject to change without notice. Changes may appear prior to their effective date.

Brand name products are listed in CAPS and generic products are listed in italics. Drugs with an asterisk (*) require Prior Authorization.

A Abiraterone (ZYTIGA) ACTIMMUNE
ADAGEN ADAKVEO ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ADBRY ADCIRCA adefovir (HEPSERA) ADEMPAS ADVATE ADYNOVATE AFINITOR AFSTYLA ALDURAZYME ALECENSA ALHEMO ALPHANATE ALPHANINE SD ALPROLIX ALTUVIIIO ALYFTREK ALYGLO alyq (ADCIRCA) APOKYN apomorphine (APOKYN) ARALAST NP ARANESP ARCALYST AUSTEDO (XR) AVEED AVONEX
B BALVERSA BARACLUDE
BAVENCIO BCG VACCINE (TICE STRAIN) BELEODAQ BELRAPZO bendamustine (TREANDA) BENDEKA BENEFIX BENLYSTA BERINERT BESPONSA betaine powder (CYSTADANE) BETASERON
BETHKIS bexarotene (TARGRETIN) BIVIGAM bleomycin bosentan (TRACLEER) BOSULIF BRAFTOVI BRIUMVI BRIXADI BRONCHITOL BRUKINSA BUPHENYL C CABOMETYX CAMCEVI CAMPTOSAR CAMZYOS capecitabine (XELODA) carglumic acid (CARBAGLU) CAYSTON CERDELGA CEREZYME cetrorelix (CETROTIDE) CETROTIDE CHORIONIC GONADOTROPIN CIMZIA cinacalcet (SENSIPAR) CINRYZE cladribine (MAVENCLAD) COAGADEX COMETRIQ COPIKTRA CORIFACT CORTROPHIN COTELLIC CRYSVITA CUTAQUIG CUVITRU CYRAMZA CYSTAGON cytarabine CYTOGAM CYTOVENE D dalfampridine ER (AMPYRA) DARZALEX DARZALEX FASPRO DAURISMO decitabine (DACOGEN)

*Prior Authorization required

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Last Revised 05-01-2026 deferasirox (EXJADE; JADENU) deferiprone (FERRIPROX) DEMSER deferoxamine (DESFERAL) deflazacort tabs (EMFLAZA) DESFERAL desmopressin dichlorphenamide
(KEVEYIS) dimethyl fumarate (TECFIDERA) dofetilide (TIKOSYN) DOJOLVI DOPTELET droxidopa (NORTHERA) DYSPORT E EBGLYSS EGRIFTA EGRIFTA WR KIT ELAPRASE ELELYSO ELFABRIO ELIGARD ELITEK ELLENCE ELOCTATE eltrombopag (PROMACTA) EMPLICITI ENBREL
ENDARI ENHERTU ENJAYMO ENSPRYNG entecavir (BARACLUDE) ENTYVIO EPCLUSA EPIDIOLEX epirubicin (ELLENCE) EPOGEN epoprostenol (FLOLAN, VELETRI) ERBITUX eribulin (HALAVEN) erlotinib (TARCEVA) ESBRIET TAB ESPEROCT ETOPOPHOS etoposide (TOPOSAR) EVENITY everolimus (AFINITOR; ZORTRESS) EXJADE F FABRAZYME FASENRA FEIBA FENSOLVI FILSPARI FIRAZYR
FIRMAGON FLEBOGAMMA FLOLAN fludarabine fluorouracil FOLLISTIM AQ FULPHILA FYLNETRA G GAMASTAN GAMMAGARD GAMMAKED GAMMAPLEX GAMUNEX-C ganirelix GATTEX GAZYVA gefitinib (IRESSA) GIVLAARI GLASSIA glatiramer (COPAXONE)
GLEEVEC glycerol phenol liquid (RAVICTI) GONAL-F GRANIX H HAEGARDA HALAVEN HARVONI HEMLIBRA HEMOFIL M HEPAGAM B HIZENTRA HUMATE-P HYMPAVZI HYQVIA HYRIMOZ I IBRANCE * icatibant (FIRAZYR)

• IDELVION IDHIFA ILARIS ILUMYA imatinib (GLEEVEC) IMFINZI IMJUDO INGREZZA INLYTA INQOVI INREBIC IQIRVO IRESSA irinotecan (CAMPTOSAR) ITOVEBI IXEMPRA IXINITY J JADENU JAKAFI JETREA JEVTANA JIVI K KADCYLA KALBITOR KALYDECO KANUMA KESIMPTA KEVZARA KEYTRUDA KISQALI KITABIS KOATE KOGENATE FS KOVALTRY KRYSTEXXA KUVAN KYLEENA L lanreotide (SOMATULINE) lapatinib ditosylate (TYKERB) LEMTRADA lenalidomide
  (REVLIMID) LENVIMA LEUKINE leuprolide (LUPRON) LILETTA LONSURF LORBRENA LUMAKRAS LUMIZYME LUPRON DEPOT LYNPARZA M MAVYRET MAYZENT MEKINIST MEKTOVI MENOPUR mercaptopurine susp (PURIXAN SUS) MESNEX metyrosine (DEMSER) mifepristone (KORLYM) miglustat (ZAVESCA) MIRENA mitomycin mitoxantrone MULPLETA MYLOTARG MYOBLOC N NAGLAZYME NERLYNX nelarabine (ARRANON) NEULASTA NEUPOGEN *

*Prior Authorization required

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Last Revised 05-01-2026 NEXAVAR NEXPLANON nilotinib (TASIGNA) NINLARO NIPENT nitisinone (NITYR, ORFADIN) NIVESTYM NORDITROPIN
NORTHERA NOURIANZ NOVAREL NOVOEIGHT NOVOSEVEN NPLATE NUBEQA NUCALA NULOJIX NUPLAZID NUWIQ NYVEPRIA O OBIZUR OCREVUS OCREVUS ZUNOVO OCTAGAM octreotide (SANDOSTATIN) ODOMZO OFEV OMVOH ONIVYDE ONPAGO ONUREG OPDUALAG INJ OPFOLDA OPSUMIT OPSYNVI ORALAIR ORENITRAM ORKAMBI OTEZLA OVIDREL P PADCEV PALYNZIQ pamidronate PANZYGA pazopanib (VOTRIENT) PEGASYS PEG-INTRON PERJETA PHEBURANE PHESGO PIASKY pirfenidone (ESBRIET) PLEGRIDY POMALYST POTELIGEO PREGNYL PRIVIGEN PROFILNINE PROLIA PROMACTA PULMOZYME PURIXAN PYZCHIVA Q R RAVICTI REBIF REBLOZYL RECLAST RELEUKO REMODULIN RETACRIT RETEVMO REVATIO REVLIMID RIABNI ribavirin RINVOQ RITUXAN RITUXAN HYCELA RIVFLOZA RIXUBIS ROLVEDON ROZLYTREK RUBRACA RUCONEST RUXIENCE RUZURGI
RYDAPT S SABRIL SAMSCA SANDOSTATIN SANDOSTATIN LAR sapropterin (KUVAN) SARCLISA SEVENFACT SEROSTIM
sildenafil (REVATIO) SIMPONI ARIA IV SKYLA SKYRIZI sodium phenylbutyrate (BUPHENYL) SOGROYA SOMATULINE SOMAVERT sorafenib (NEXAVAR) SPRYCEL STIMUFEND STIVARGA SUBLOCADE sunitinib (SUTENT) SUPPRELIN SUTENT SYMDEKO SYNAGIS T TABRECTA tadalafil (ADCIRCA) TADLIQ TAFINLAR TAGRISSO TALTZ TALZENNA TARGTETIN TASIGNA

tasimelteon (HETLIOZ) TAZVERIK temozolomide (TEMODAR) teriparatide (FORTEO)
tetrabenazine (XENAZINE) THALOMID THYROGEN TIKOSYN tiopronin (THIOLA) tiopronin dr (THIOLA EC) TIVDAK TOBI tobramycin (TOBI; BETHKIS) tolvaptan (SAMSCA) TRACLEER TREANDA TRELSTAR TREMFYA treprostinil (REMODULIN) TRETTEN TRIKAFTA TROGARZO TRUXIMA TYENNE TYKERB TYMLOS TYSABRI TYVASO U UDENYCA UPTRAVI USTEKINUM-AAUZ V VECTIBIX VELCADE VELETRI VEMLIDY VENTAVIS
VERZENIO vigabatrin (SABRIL) VIMIZIM vinblastine vincristine VITRAKVI VIVIMUSTA VIVITROL VIZIMPRO VONVENDI SIMPONI SC *

*Prior Authorization required

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Last Revised 05-01-2026 VOSEVI VOTRIENT VOXOGO VPRIV VYNDAMAX VYNDAQEL VYVGART HYTR W WILATE WINREVAIR X XALKORI XDEMVY XELJANZ XELJANZ XR XELODA XEMBIFY XENAZINE XEOMIN XGEVA XIAFLEX XOLAIR XOSPATA XTANDI XYNTHA Y YERVOY YESINTEK YONSA Z ZALTRAP ZARXIO ZEJULA ZELBORAF ZEMAIRA ZEPOSIA ZEPZELCA ZIEXTENZO

ZOLADEX *

zoledronic acid (RECLAST) ZOLINZA ZORTRESS ZURZUVAE
ZYDELIG ZYKADIA *

Limited Distribution Drug List

Due to manufacturer restrictions, a small number of specialty drugs used to treat rare or uncommon conditions may be available only through specific Preferred retail pharmacies and are referred to as Limited Distribution Drugs. The following list of Limited Distribution Specialty drugs are not available through CVS Specialty however they may be obtained through a specific Preferred retail pharmacy. The Specialty Drug Pharmacy Program copayments will apply to these medications. Please contact the Specialty Pharmacy Program at 1-888-346-3731 for assistance with finding the appropriate pharmacy.

A AGAMREE AKEEGA ALUNBRIG AQNEURSA ARIKAYCE ATTRUBY AUGTRYO AVMAPKI PAK FAKZYNJA AYVAKIT B BESREMI BOTOX BRUKINSA BYLVAY C CALQUENCE CAPRELSA CARBAGLU CHOLBAM CRENESSITY CYSTADANE CYSTADROPS CYSTARAN D DANZITEN DAYBUE DIACOMIT DUVYZAT E EMFLAZA EMPAVELI ENSACOVE EVRYSDI F FABHALTA FERRIPROX FILSUVEZ FINTEPLA FIRDAPSE FOTIVDA FRUZAQLA G GALAFOLD GAVRETO GILOTRIF GOMEKLI H HETLIOZ HYFTOR GEL I IBTROZI ICLUSIG IMBRUVICA IMKELDI INBRIJA INCRELEX
ISTURISA IWILFIN J JAVYGTOR JAYPIRCA JAYTHARI
JOENJA JUXTAPID JYNARQUE K KEVEYIS KORLYM KOSELUGO KRAZATI KYMBEE L LAZCLUZE LIVMARLI LUPKYNIS LYTGOBI M MATULANE MIPLYFFA MODEYSO MYALEPT

*Prior Authorization required

Products distributed by CVS Caremark Specialty Pharmacy, as well as products covered by a plan member’s prescription benefit plan, may change from time to time. in addition, a plan member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance on this document at any time. Last Revised 05-01-2026 MYCAPSSA N NITYR O OGSIVEO OJEMDA OJJAARA OLPRUVA ORFADIN ORGOVYX ORLADEYO ORSERDU OXERVATE P PALFORZIA PEMAZYRE PHYRAGO PIQRAY PROCYSBI PROLASTIN-C PYRUKYND Q QFITLIA QINLOCK R RECORLEV REVCOVI REVUFORJ REZLIDHIA REZUROCK ROMVINZA S SAJAZIR SCEMBLIX SEPHIENCE SIGNIFOR (LAR) SKYCLARYS SPEVIGO STRENSIQ T TARPEYO TASCENSO ODT TAVALISSE TAVNEOS TEPEZZA TEPMETKO TEVIMBRA THIOLA THIOLA EC TIBSOVO TORPENZ TRODELVY TRUQAP TRYNGOLZA TUKYSA TURALIO U V VALCHLOR VANFLYTA VENCLEXTA vigadrone powder VIGAFYDE VIJOICE VONJO VORANIGO VOWST VOYDEYA VYEPTI VYLOY VYONDYS 53
W WAINUA WAYRILZ WELIREG X XERMELO XOLREMDI XPOVIO Y YORVIPATH Z ZAVESCA ZILBRYSQ ZTALMY*