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Specialty Drugs
(effective October 1, 2016)
Specialty drugs are high-cost, prescription drugs used to treat serious or chronic medical conditions and require special handling (such as
refrigeration), administration or monitoring. The following is a list of specialty drugs that may be covered through either your prescription or
medical plan; however other specialty drugs may also be covered. To learn more about your specific drug benefit or to use the Drug Cost
Tool, log in to My Account at www.carefirst.com/myaccount and click on Drug & Pharmacy Resources under Quick Links or call
CareFirst Pharmacy Services at 800-241-3371. This list represents brand products in CAPS and generic products in lowercase italics.
SPECIALTY DRUGS
ACROMEGALY
octreotide acetate
(SANDOSTATIN) Rx,MB ES PA SI
SANDOSTATIN LAR MB mPA
SIGNIFOR LAR † MB
SOMATULINE DEPOT MB mPA
SOMAVERT * Rx,MB ES PA SI
ALCOHOL / OPIOID DEPENDENCY
VIVITROL MB
ALLERGEN IMMUNOTHERAPY
ORALAIR * Rx
ALLERGIC ASTHMA
CINQAIR * MB
NUCALA * MB
XOLAIR * MB mPA
ALPHA-1 ANTITRYPSIN DEFICIENCY
ARALAST NP * MB mPA
GLASSIA * MB mPA
PROLASTIN-C † MB mPA
ZEMAIRA * MB mPA
NEXPLANON * MB
SKYLA * MB
CRYOPYRIN-ASSOCIATED PERIODIC
SYNDROMES
ARCALYST * Rx,MB ES PA SI
ILARIS * MB mPA
KINERET Rx,MB ES PA SI
IGF-1 Deficiency
CUSHING’S SYNDROME
HEMATOPOIETICS
KORLYM Rx PA
SIGNIFOR † Rx,MB PA SI
†
CYSTIC FIBROSIS
BETHKIS * Rx,MB ES PA
CAYSTON † Rx,MB PA
KALYDECO * Rx ES PA
KITABIS PAK Rx,MB ES PA
ORKAMBI Rx ES PA
PULMOZYME Rx,MB ES PA
TOBI PODHALER * Rx,MB ES PA
tobramycin inhalation solution
(TOBI) Rx,MB ES PA
DUPUYTREN’S CONTRACTURE
XIAFLEX * MB
ANEMIA
ARANESP Rx,MB ES PA SI
EPOGEN Rx,MB ES PA SI
MIRCERA † Rx,MB PA SI
PROCRIT Rx,MB ES PA SI
BOTULINUM TOXINS
ELECTROLYTE DISORDERS
SAMSCA Rx ES PA
STRENSIQ † Rx,MB PA
GASTROINTESTINAL DISORDERS-OTHER
BOTOX MB mPA
DYSPORT MB mPA
MYOBLOC MB mPA
XEOMIN * MB mPA
CHOLBAM Rx PA
GATTEX * Rx,MB ES PA SI
OCALIVA Rx ES PA
CARDIAC DISORDERS
KRYSTEXXA MB
dofetilide (TIKOSYN) Rx ES PA
NORTHERA * Rx ES PA
COAGULATION DISORDERS
CEPROTIN * MB
CONTRACEPTIVES
LILETTA † MB
MIRENA * MB
*
†
ES
MB
mPA
PA
Rx
Rx,MB
SI
SAIZEN Rx,MB ES PA SI
SEROSTIM * Rx,MB ES PA SI
TEV-TROPIN Rx,MB ES PA SI
ZOMACTON Rx,MB ES PA SI
ZORBTIVE Rx,MB ES PA SI
GOUT
GROWTH HORMONE & RELATED
DISORDERS
Growth Hormone Disorders
GENOTROPIN Rx,MB ES PA SI
HUMATROPE Rx,MB ES PA SI
NORDITROPIN Rx,MB ES PA SI
NUTROPIN AQ Rx,MB ES PA SI
OMNITROPE Rx,MB ES PA SI
Indicates Limited Distribution products distributed by CVS Specialty Pharmacy.
Indicates Limited Distribution products not distributed by CVS Specialty Pharmacy.
Delivered through the CareFirst Exclusive Specialty Pharmacy network.
Covered under medical benefit.
Prior authorization required for medical benefits coverage.
Prior authorization required for prescription benefits coverage.
Covered under prescription benefit.
May be covered under either prescription or medical benefits. Please consult your plan to determine coverage.
Self-injectable product.
INCRELEX * Rx,MB ES PA SI
MOZOBIL * MB
HEMOPHILIA, VON WILLEBRAND DISEASE
& RELATED BLEEDING DISORDERS
ADVATE MB mPA
ADYNOVATE * MB
AFSTYLA MB
ALPHANATE MB mPA
ALPHANINE SD MB mPA
ALPROLIX MB mPA
BEBULIN VH MB
BEBULIN MB mPA
BENEFIX MB mPA
COAGADEX MB
CORIFACT * MB
ELOCTATE MB mPA
FEIBA NF MB mPA
FEIBA VH MB mPA
HELIXATE FS MB mPA
HEMOFIL M MB mPA
HUMATE-P MB mPA
IDELVION MB
IXINITY MB
KOATE-DVI MB mPA
KOGENATE FS MB mPA
KOVALTRY MB
MONOCLATE-P MB mPA
MONONINE MB mPA
NOVOEIGHT MB
NOVOSEVEN RT MB mPA
NUWIQ MB
OBIZUR * MB
PROFILNINE SD MB mPA
RECOMBINATE MB mPA
RIASTAP MB
RIXUBIS MB mPA
STIMATE MB
TRETTEN * MB
WILATE MB mPA
XYNTHA MB mPA
HEPATITIS C
DAKLINZA Rx ES PA
EPCLUSA Rx ES PA
HARVONI Rx ES PA
INTRON A * Rx,MB ES PA SI
OLYSIO Rx ES PA
PEGASYS Rx,MB ES PA SI
REBETOL SOLUTION Rx ES PA
RIBAPAK Rx ES PA
RIBASPHERE Rx ES PA
ribavirin caps (REBETOL) Rx ES PA
ribavirin tabs (COPEGUS) Rx ES PA
SOVALDI Rx ES PA
TECHNIVIE Rx ES PA
VIEKIRA PAK Rx ES PA
ZEPATIER Rx ES PA
HEREDITARY ANGIOEDEMA
HYQVIA MB
MICRHOGAM MB
NABI-HB MB
OCTAGAM * MB mPA
PRIVIGEN * MB mPA
RHOGAM MB
RHOPHYLAC MB
VARIZIG * MB
WINRHO SDF MB
KANUMA † MB
LUMIZYME * MB mPA
NAGLAZYME * MB mPA
ORFADIN † Rx PA
PROCYSBI † Rx PA
VIMIZIM * MB mPA
VPRIV * MB mPA
ZAVESCA † Rx PA
IMMUNE (IDIOPATHIC)
THROMBOCYTOPENIC PURPURA
MYALEPT † Rx,MB PA SI
NPLATE MB mPA
PROMACTA * Rx ES PA
INFECTIOUS DISEASE
ACTIMMUNE * Rx,MB ES PA SI
ALFERON N * MB
INFERTILITY
EGRIFTA * Rx,MB ES PA SI
FUZEON Rx ES PA SI
BRAVELLE Rx,MB SI
CETROTIDE Rx,MB SI
chorionic gonadotropin
(NOVAREL, PREGNYL) Rx,MB SI
FOLLISTIM AQ Rx,MB SI
GANIRELIX Rx,MB SI
GONAL-F Rx,MB SI
MENOPUR Rx,MB SI
OVIDREL Rx,MB SI
REPRONEX Rx,MB SI
HORMONAL THERAPIES
INFLAMMATORY BOWEL DISEASE
BERINERT * Rx,MB ES PA mPA SI
CINRYZE * Rx,MB ES PA mPA SI
FIRAZYR * Rx,MB ES PA SI
KALBITOR * Rx,MB ES PA mPA SI
RUCONEST * Rx,MB ES PA SI
HIV MEDICATIONS
AVEED * MB
ELIGARD MB mPA
FIRMAGON MB mPA
H.P. ACTHAR GEL * Rx,MB ES PA mPA SI
leuprolide acetate (LUPRON) Rx,MB ES PA SI
LUPANETA PACK MB
LUPRON DEPOT MB mPA
NATPARA * Rx,MB PA SI
SUPPRELIN LA * MB
TRELSTAR MB mPA
VANTAS MB mPA
ZOLADEX MB mPA
IMMUNE DEFICIENCIES & RELATED
DISORDERS
ADAGEN MB mPA
BIVIGAM * MB mPA
CARIMUNE NF MB mPA
CYTOGAM MB mPA
FLEBOGAMMA DIF MB
FLEBOGAMMA MB mPA
GAMASTAN S/D MB mPA
GAMMAGARD LIQUID MB mPA
GAMMAGARD S/D MB mPA
GAMMAKED MB mPA
GAMMAPLEX * MB mPA
GAMUNEX-C MB mPA
HEPAGAM B MB
HIZENTRA * MB mPA
HYPERHEP B MB
HYPERRHO S/D MB
*
†
ES
MB
mPA
PA
Rx
Rx,MB
SI
CIMZIA Rx,MB ES PA mPA SI
ENTYVIO MB mPA
HUMIRA Rx ES PA SI
REMICADE MB mPA
SIMPONI Rx,MB ES PA SI
TYSABRI * MB mPA
IRON OVERLOAD
deferoxamine (DESFERAL) MB
EXJADE * Rx ES PA
FERRIPROX † Rx PA
JADENU * Rx PA
LIPID DISORDERS
JUXTAPID † Rx PA
KYNAMRO * Rx,MB ES PA SI
LIPID DISORDERS - PCSK9 INHIBITORS
PRALUENT Rx ES PA SI
REPATHA Rx ES PA SI
LYSOSOMAL STORAGE DISORDERS
ALDURAZYME * MB mPA
CERDELGA * Rx ES PA
CEREZYME * MB mPA
CYSTAGON * Rx ES PA
CYSTARAN † Rx PA
ELAPRASE * MB mPA
ELELYSO † MB mPA
FABRAZYME * MB mPA
Indicates Limited Distribution products distributed by CVS Specialty Pharmacy.
Indicates Limited Distribution products not distributed by CVS Specialty Pharmacy.
Delivered through the CareFirst Exclusive Specialty Pharmacy network.
Covered under medical benefit.
Prior authorization required for medical benefits coverage.
Prior authorization required for prescription benefits coverage.
Covered under prescription benefit.
May be covered under either prescription or medical benefits. Please consult your plan to determine coverage.
Self-injectable product.
LIPODYSTROPHY
MOVEMENT DISORDERS
APOKYN * Rx ES PA SI
DUOPA † MB
NUPLAZID * Rx ES PA
tetrabenazine (XENAZINE) * Rx ES PA
MULTIPLE SCLEROSIS
AMPYRA * Rx ES PA
AUBAGIO * Rx ES PA
AVONEX Rx,MB ES PA SI
BETASERON Rx,MB ES PA SI
EXTAVIA Rx,MB ES PA SI
GILENYA Rx ES PA
glatiramer acetate
(COPAXONE) Rx,MB ES PA SI
LEMTRADA * MB mPA
PLEGRIDY * Rx,MB ES PA SI
REBIF Rx,MB ES PA SI
TECFIDERA * Rx ES PA
TYSABRI * MB mPA
ZINBRYTA * Rx ES PA SI
NEUTROPENIA
GRANIX Rx,MB ES PA SI
LEUKINE Rx,MB ES PA SI
NEULASTA Rx,MB ES PA SI
NEUPOGEN Rx,MB ES PA SI
ZARXIO Rx,MB ES PA SI
ONCOLOGY - INJECTABLE
ABRAXANE MB mPA
ADCETRIS * MB
ALIMTA MB mPA
ARZERRA * MB
AVASTIN * MB mPA
azacitidine (VIDAZA) Rx,MB ES PA SI
BELEODAQ * MB
BENDEKA * MB
BLINCYTO * MB
CYRAMZA † MB
DARZALEX * MB
decitabine (DACOGEN) * MB
DOCEFREZ MB mPA
ELSPAR * MB
EMPLICITI * MB
ERBITUX * MB mPA
ERWINAZE MB
EVOMELA * MB
FOLOTYN * MB
FUSILEV * MB
GAZYVA * MB
GEMZAR MB mPA
HALAVEN * MB
HERCEPTIN * MB mPA
IMLYGIC † MB
INTRON A * Rx,MB ES PA SI
ISTODAX * MB
IXEMPRA * MB
JEVTANA * MB
KADCYLA * MB mPA
KEYTRUDA * MB
KYPROLIS * MB
levoleucovorin calcium (FUSILEV) * MB
LEVOLEUCOVORIN CALCIUM * MB
mitoxantrone (NOVANTRONE) * MB
ONCASPAR * MB
ONIVYDE † MB
OPDIVO * MB
oxaliplatin MB mPA
PERJETA * MB mPA
PORTRAZZA † MB
PROLEUKIN * MB
PROVENGE MB mPA
RITUXAN * MB mPA
SYLATRON * Rx,MB ES PA SI
SYLVANT MB
SYNRIBO † MB
TAXOTERE MB mPA
TECENTRIQ MB
TEMODAR MB
THYROGEN * MB
TORISEL * MB
TREANDA * MB mPA
UNITUXIN † MB
VALSTAR * MB
VECTIBIX * MB
VELCADE * MB mPA
XGEVA MB mPA
YERVOY * MB mPA
YONDELIS * MB
ZALTRAP * MB
zoledronic acid (ZOMETA) MB mPA
ONCOLOGY - ORAL / TOPICAL
AFINITOR Rx ES PA
ALECENSA * Rx ES PA
bexarotene (TARGRETIN) Rx ES PA
BOSULIF Rx ES PA
CABOMETYX * Rx ES PA
capecitabine (XELODA) Rx ES PA
CAPRELSA † Rx PA
COMETRIQ † Rx PA
COTELLIC * Rx ES PA
ERIVEDGE * Rx ES PA
FARYDAK * Rx PA
GILOTRIF † Rx PA
HYCAMTIN * Rx ES PA
IBRANCE * Rx ES PA
ICLUSIG † Rx PA
imatinib (GLEEVEC) Rx ES PA
IMBRUVICA † Rx PA
INLYTA * Rx ES PA
IRESSA * Rx PA
JAKAFI * Rx ES PA
LENVIMA † Rx PA
*
†
ES
MB
mPA
PA
Rx
Rx,MB
SI
LONSURF Rx ES PA
LYNPARZA Rx PA
MEKINIST * Rx ES PA
NEXAVAR * Rx ES PA
NINLARO * Rx ES PA
ODOMZO Rx ES PA
POMALYST * Rx ES PA
PURIXAN * Rx
REVLIMID * Rx ES PA
SPRYCEL Rx ES PA
STIVARGA * Rx ES PA
SUTENT Rx ES PA
TAFINLAR * Rx ES PA
TAGRISSO * Rx PA
TARCEVA * Rx ES PA
TARGRETIN GEL Rx ES PA
TASIGNA Rx ES PA
temozolomide (TEMODAR) Rx ES PA
THALOMID Rx ES PA
TYKERB * Rx ES PA
VALCHLOR † Rx PA
VENCLEXTA † Rx PA
VISTOGARD † Rx,MB
VOTRIENT * Rx ES PA
XALKORI * Rx ES PA
XTANDI * Rx ES PA
ZELBORAF * Rx ES PA
ZOLINZA Rx ES PA
ZYDELIG † Rx PA
ZYKADIA * Rx ES PA
ZYTIGA Rx ES PA
PSORIASIS
OSTEOARTHRITIS
SENSIPAR Rx ES PA
EUFLEXXA MB mPA
GEL-ONE MB mPA
GELSYN-3 MB mPA
GENVISC 850 * MB mPA
HYALGAN MB mPA
HYMOVIS MB mPA
MONOVISC MB mPA
ORTHOVISC MB mPA
SUPARTZ FX MB mPA
SYNVISC ONE MB
SYNVISC MB
OSTEOPOROSIS
FORTEO Rx,MB ES PA SI
PROLIA MB mPA
zoledronic acid (RECLAST) MB mPA
PAIN MANAGEMENT
PRIALT MB
PAROXYSMAL NOCTURNAL
HEMOGLOBINURIA
SOLIRIS * MB mPA
PHENYLKETONURIA
KUVAN * Rx ES PA
PRE-TERM BIRTH
MAKENA * MB
Indicates Limited Distribution products distributed by CVS Specialty Pharmacy.
Indicates Limited Distribution products not distributed by CVS Specialty Pharmacy.
Delivered through the CareFirst Exclusive Specialty Pharmacy network.
Covered under medical benefit.
Prior authorization required for medical benefits coverage.
Prior authorization required for prescription benefits coverage.
Covered under prescription benefit.
May be covered under either prescription or medical benefits. Please consult your plan to determine coverage.
Self-injectable product.
COSENTYX * Rx,MB ES PA SI
ENBREL Rx ES PA SI
HUMIRA Rx ES PA SI
OTEZLA * Rx ES PA
OTREXUP Rx,MB ES PA SI
RASUVO Rx,MB ES PA SI
REMICADE MB mPA
STELARA Rx,MB ES PA mPA SI
TALTZ * Rx ES PA SI
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA Rx ES PA
ADEMPAS * Rx ES PA
epoprostenol sodium (FLOLAN) * MB mPA
LETAIRIS * Rx ES PA
OPSUMIT * Rx ES PA
ORENITRAM * Rx ES PA
REMODULIN * MB mPA
sildenafil (REVATIO) Rx ES PA
TRACLEER * Rx ES PA
TYVASO * Rx,MB ES PA
UPTRAVI Rx ES PA
VELETRI * MB mPA
VENTAVIS * Rx,MB ES PA
PULMONARY DISORDERS-OTHER
ESBRIET * Rx ES PA
OFEV † Rx PA
RENAL DISEASE
RESPIRATORY SYNCYTIAL VIRUS
SYNAGIS MB mPA
RETINAL DISORDERS
EYLEA * MB mPA
ILUVIEN * MB
LUCENTIS * MB mPA
MACUGEN * MB
OZURDEX * MB
RETISERT * MB
VISUDYNE * MB
RHEUMATOID ARTHRITIS
ACTEMRA * Rx,MB ES PA mPA SI
CIMZIA Rx,MB ES PA mPA SI
ENBREL Rx ES PA SI
HUMIRA Rx ES PA SI
KINERET † Rx,MB PA SI
ORENCIA Rx,MB ES PA mPA SI
OTREXUP Rx,MB ES PA SI
RASUVO Rx,MB ES PA SI
REMICADE MB mPA
SIMPONI ARIA MB mPA
SIMPONI Rx,MB ES PA SI
XELJANZ Rx ES PA
SEIZURE DISORDERS
H.P. ACTHAR GEL * Rx,MB ES PA mPA SI
SABRIL * Rx ES PA
SLEEP DISORDERS
HETLIOZ † Rx PA
*
†
ES
MB
mPA
PA
Rx
Rx,MB
SI
SYSTEMIC LUPUS ERYTHEMATOSUS
BENLYSTA MB mPA
Indicates Limited Distribution products distributed by CVS Specialty Pharmacy.
Indicates Limited Distribution products not distributed by CVS Specialty Pharmacy.
Delivered through the CareFirst Exclusive Specialty Pharmacy network.
Covered under medical benefit.
Prior authorization required for medical benefits coverage.
Prior authorization required for prescription benefits coverage.
Covered under prescription benefit.
May be covered under either prescription or medical benefits. Please consult your plan to determine coverage.
Self-injectable product.
UREA CYCLE DISORDERS
CARBAGLU † Rx PA
phenylbutyrate sodium (BUPHENYL) Rx ES PA
RAVICTI * Rx ES PA
For CVS Specialty Pharmacy™, please call (855) 264-3237.
Products distributed by CVS Specialty Pharmacy, as well as products covered by a plan member's prescription or medical benefit plan may change from time to time. In addition, a plan
member's specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and
CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’
Registered trademark of CareFirst of Maryland, Inc.
©2016. All rights reserved.
SUM2654-1P (10/01/16)