071 Form

Pharmacy Medical Policy Injectable Specialty Medication Coverage Table of Contents
1-Authorization Information 2-Medication List
3-Footnotes
4-Policy History 5-Forms

Policy Number: 071 BCBSA Reference Number: None Related Policies • Quality Care Dosing guidelines may apply to the following medications and can be found in Medical Policy #621A • Medical Utilization Management (MED UM) Policy #033

Prior Authorization Information ☐ Prior Authorization ☐ Step Therapy ☐ Quality Care Dosing ☒ Benefits

Pharmacy Operations: Tel: 1-800-366-7778 Fax: 1-800-583-6289 Policy last updated 5/2026 Pharmacy (Rx) or Medical (MED) benefit coverage ☒ Rx ☐ MED To request for coverage: Physicians may call, fax, or mail the attached form (Formulary Exception/Prior Authorization form) to the address below.
Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department 25 Technology Place Hingham, MA 02043
Policy applies to Commercial Members with the custom BCBSMA formulary:
• Managed Care (HMO/POS) • PPO/EPO
• Indemnity

This policy applies to all members, except: • Medicare Advantage members • Federal Employee Program members • Members with Medicare Supplemental Plans

Injectable Specialty Medication Coverage Information
(As of January 1, 2020) The medications included in this policy are covered under the member’s pharmacy benefits only when filled through a specialty pharmacy in our network. Exceptions are noted where applicable in the

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medication list on the following pages. A valid prescription from a licensed health care provider is required to fill these medications.

Some medications may also be subject to other pharmacy management programs, such as Step Therapy, Prior Authorization, or Quality Care Dosing, or have other coverage requirements. For more information about these medications, use our Medication Lookup tool:

• Medication Lookup for Providers: bluecrossma.com/provider
• Medication Lookup for Members: bluecrossma.com/medications

Important: Providers can’t buy and bill us for the medications listed in this policy using the member’s medical benefits. (There are exceptions for providers in Massachusetts to buy and bill certain medications that are noted on the list.)

Additional Coverage Information

Medications Self- Administered at Home
Medications Administered in a Doctor’s Office Medications Administered by a Home Infusion Therapy Provider Ordering the Medication The prescriber orders the medication through an in- network retail specialty pharmacy. The prescriber orders the medication through an in- network retail specialty pharmacy for delivery to the prescriber’s office or an outpatient clinic for administration. The prescriber requests prior authorization for this service. They refer the member to a home infusion therapy provider who procures the medication and administers it in the member’s home. Paying for the Medication The member is responsible for out-of-pocket prescription costs, such as a copay, deductible, or co- insurance. The member is responsible for any prescription costs (such as a copay, deductible, or co-insurance) and the cost of the office visit (such as a copay, deductible, or co- insurance). The member is responsible for any applicable cost sharing outlined under the home care benefit (such as a copay, deductible, or co- insurance).

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List of Medications Covered Only Under the Pharmacy Benefit1

This isn’t a complete list of covered medications, and inclusion on the list doesn’t guarantee coverage. Some members, depending on their pharmacy plan, may not be covered for these medications. Providers should check a member’s eligibility and benefits.

Medication Date added to this list Medication Date added to this list Abrilada Jan. 1, 2024 Fuzeon Jan. 1, 2011 Actimmune

Jan. 1, 2011 Fyremadel Jan. 1, 2011 Adalimumab-aacf June 1, 2025 Gamastan SD3 Sept. 1, 2015 Adalimumab-aaty June 1, 2025 Gammagard liquid/ ERC 3 Sept. 1, 2015 Adalimumab-adaz Jan. 1, 2024 Gammaplex3 Sept. 1, 2015 Adalimumab-adbm Jan. 1, 2024 Gamunex-C3 Sept. 1, 2015 Adalimumab-bwwd March 15, 2026 Gammaked3 Sept. 1, 2015 Adalimumab-fkjp Jan. 1, 2024 Ganirelix Jan. 1, 2011 Adalimumab-ryvk June 1, 2025 Gel-One2 Jan. 1, 2011 Amjevita Feb. 8, 2023 GelSyn-32 July 1, 2021 Aranesp Jan. 1, 2011 Genotropin Jan. 1, 2011 Arcalyst Jan. 1, 2011 Gammaplex3 Sept. 1, 2015 Avonex Jan. 1, 2011 Genvisc Jan. 1, 2011 Betaseron Jan. 1, 2011 Glatiramer Oct. 3,2017 Bivigam3 Sept. 1, 2015 Glatopa Apr. 16,2015
Bonsity August 1, 2025 Gonal F Jan. 1, 2011 Botox3 Sept. 1, 2015 Gonal F RFF Jan. 1, 2011 Bimzelx Nov. 2, 2023 Hadlima June 1, 2025 Bydureon Jan. 1, 2025 Hizentra3 Sept. 1, 2015 Byetta Jan. 1, 2025 Humatrope Jan. 1, 2011 Bynfezia July 1, 2021 Humira Jan. 1, 2011 Cetrotide Jan. 1, 2011 Hulio June 1, 2025 Chorionic Gonadotropin Jan. 1, 2011 Hyalgan2 Jan. 1, 2011 Cimzia Jan. 1, 2011 Hyrimoz Jan. 1, 2024 Cyltezo Jan. 1, 2024 HyQvia3 Sept 12, 2014 Copaxone Jan. 1, 2011 Hymovis / Hymovis One2 March 15, 2026 Cosentyx July 1, 2021 Idacio Jan. 1, 2024 Daxxify Jan. 1,2024 Ilaris Jan. 1, 2011 Dupixent July 1, 2021 Ilumya July 1, 2023 Durolane Mar 5, 2018 Imuldosa Oct. 1, 2025 Dysport3 Sept. 1, 2015 Increlex Jan. 1, 2011 Ebglyss Sept. 26, 2024 Kesimpta Sept 1,2020 Enbrel Jan. 1, 2011 Infliximab3 Jan. 1, 2011 Enspryng Sept. 1,2020 Kevzara July 1, 2021 Epogen Jan. 1, 2011 Kineret Jan. 1, 2011 Euflexxa2 Jan. 1, 2011 Leuprolide (non-Depot form) Jan. 1, 2011 Exenatide (Generic Byetta) Sept. 15, 2025 Leqvio Jan. 1, 2023 Extavia Jan. 1, 2011 Liraglutide Jan 1, 2025 Fasenra July 1, 2021 Menopur Jan. 1, 2011 Forteo Jan. 1, 2011 Monovisc2 July 1, 2021

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Medication Date added to this list Medication Date added to this list Mounjaro Jan 1, 2025 Steqeyma (SC, IV) June 1, 2025
Myobloc3 Sept. 1, 2015 Skyrizi July 1, 2023 Flebogamma / Dif 3 Sept. 1, 2015 Skytrofa Oct 21, 2021 Follistim AQ Jan. 1, 2011 Sogroya July 1, 2023 Norditropin July 1, 2021 Somavert Jan. 1, 2011 Novarel Jan. 1, 2011 Soliqua Jan 1, 2025 Nucala Jan. 1, 2011 Starjemza March 15, 2026 Nutropin AQ Jan. 1, 2011 Stelara ® (SC, IV) Jan 1, 2024 Octagam3 Sept. 1, 2015 Strensiq July 1, 2021 Octreotide (not LAR) Jan. 1, 2011 Supartz2 Jan. 1, 2011 Omnitrope Sept. 1, 2015 Synvisc2 (all forms) Jan. 1, 2011 Orfadin Jan. 1, 2011 Tegsedi July 1, 2021 Orthovisc2 Jan. 1, 2021 Teriparatide Mar 1, 2020 Otufli (SC, IV) June 1, 2025 Tezspire Jan 13, 2022 Ovidrel Jan. 1, 2011 TOBI Jan. 1, 2011 Ozempic Jan 1, 2025 Tremfya July 1, 2021 Panretin Jan. 1, 2011 Triluron July 1, 2021 Panzyga Jan. 1, 2011 Trivisc July 1, 2021 Pegasys Sept. 1, 2015 Trulicity Jan 1, 2025 Pregnyl Jan. 1, 2011 Tymlos Jan. 1, 2011 Privigen3 Jan. 1, 2011 Ustekinumab (SC, IV) June 1, 2025 Procrit Jan. 1, 2011 Ustekinumab-aauz March 15, 2026 Prolia3 Jan. 1, 2011 Ustekinumab-aekn June 1, 2025 Pulmozyme Sept. 1, 2015 Ustekinumab-ttwe (SC,IV) June 1, 2025 Pyzchiva (SC, IV) June 1, 2025 Victoza Jan 1, 2025 Rebif Jan. 1, 2011 Visco-32 Jan. 1, 2011 Remicade3 Jan. 1, 2011 Wegovy Jan 1, 2025 Ribavirin

Jan. 1, 2011 Wezlana (SC, IV) June 1, 2025 Rebif Jan. 1, 2011 Xeomin3 Sept. 1, 2015 Saizen Jan. 1, 2011 Xgeva3 Sept. 1, 2015 Sandostatin (not LAR) Jan. 1, 2011 Xultophy Jan 1, 2025 Saxenda Jan 1, 2025 Yesintek (SC, IV) June 1, 2025 Selarsdi (SC, IV) June 1, 2025 Yimmugo Jan 15, 2026 Serostim Jan. 1, 2011 Yuflyma Jan 1, 2024 Siliq July 1, 2021 Yusimry June 1, 2025 Simlandi June 1, 2025 Zepbound Jan 1, 2025 Simponi Jan. 1, 2011 Zomacton Sept. 1, 2015 Simponi Aria Jan 1, 2024

Footnotes

1. Does not apply when the medication is administered: in the emergency room; as an inpatient; at a surgical day care facility; in an ambulatory surgery center; or through home infusion therapy or dialysis.
2. This medication can be filled at any retail pharmacy. The member doesn’t need to use a retail specialty pharmacy in our network for these medications only.

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3. These medications are covered under the pharmacy benefit when filled at an in-network specialty pharmacy. However, they may be covered under the medical benefit by a doctor who practices in Massachusetts and administered based on the member’s benefits. Policy History
   Date Action 5/2026 Added Gammagard ERC line extension to listing. 3/15/2026 Added Imuldosa, Ustekinumab-AAUZ, Starjemza, Adalimumab-bwwd, Hymovis One 1/15/2026 Added Yimmugo. 1/2026 Removed Zorbtive; discontinued by the manufacturer. 9/15/2025 Added exenatide (generic Byetta) to the list. 8/2025 Added Bonsity to the list. 6/2025 Added Stelara biosimilars and updated list of adalimumab products. Steamlined any duplicative listings and removed the following discontinued agents: Adlyxin, Bravelle, Carimune, Copegus, Gamunex, Gel-Syn, Infergen, Luveris, Nordiflex, Nutropin, Panglobulin, PegIntron/Redi Pen, Rebetol, Rebetron, Repronex, Tanzeum, Tev-Tropin 1/2025 Updated to add Adlyxin, Bydureon, Byetta, Liraglutide, Mounjaro, Ozempic, Saxenda, Soliqua, Tanzeum, Trulicity, Victoza, Wegovy, Xultophy, and Zepbound to the policy. 9/2024 Updated to add Ebglyss ™as part of new drug process to line up with Dupixent ®. 1/2024 Updated to add Stelara ® IV and Simponi Aria ® to the policy. 7/2023 Reformatted Policy and Added Sogroya ® to the policy 1/2023 Updated to add Leqvio ® to the policy. 1/2022 Updated to add Tezspire to the policy.
   10/2021 Updated to add Skytrofa to the policy. 7/1/2021 Updated to add 7/1 changes and for maintenance and clean up. 9/1/2020 Updated to add Kesimpta and Enspryng to the policy. 3/1/2020 Policy developed based on current process.

   Forms To request prior authorization using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm), click the link below: https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam- assets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf OR Print and fax, Massachusetts Standard Form for Medication Prior Authorization Requests #434