This is a list of most specialty medications on the specialty tiers of the ClearScript Formulary.

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1 Specialty Drug List This is a list of most specialty medications on the specialty tiers of the ClearScript Formulary. What are specialty drugs? Specialty drugs are medications used to treat rare or complex conditions and often require special handling or monitoring. To ensure the safest, most clinically appropriate and cost-effective dispensing of these medications, your plan may require you to fill your prescriptions at a designated specialty pharmacy. Specialty pharmacies provide personalized care and offer convenient delivery to your home or other approved location. Please refer to your benefit plan documents for information on your plan s coverage for specialty medications or contact ClearScript Member Services at the number on the back of your ID Card. Important Note: This is not a complete list of all specialty medications. The drugs included on this list may not be covered by all benefit plans. Your benefit plan determines coverage for all medications. Additional coverage restrictions may apply for the medications included on this list. This list is subject to change throughout the year. abacavir abacavir-lamivudine abacavir-lamivudinezidovudine abiraterone acetate ABRAXANE ACTEMRA ACTEMRA ACTPEN ACTHREL ACTIMMUNE ADAGEN ADCETRIS ADCIRCA adefovir dipivoxil ADEMPAS adriamycin ADRIAMYCIN adrucil ADVATE ADYNOVATE AFINITOR AFINITOR DISPERZ AFSTYLA ALDURAZYME ALECENSA ALFERON N ALIMTA ALIQOPA ALKERAN ALPHANATE ALPHANINE SD ALPROLIX ALUNBRIG alyq amifostine AMPYRA APOKYN APTIVUS ARALAST NP ARANESP ARCALYST ARIKAYCE ARIXTRA ARRANON arsenic trioxide ARZERRA ASTAGRAF XL atazanavir sulfate ATGAM ATRIPLA AUBAGIO AUSTEDO AVASTIN AVONEX AVONEX PEN azacitidine BARACLUDE BAVENCIO BCG (TICE STRAIN) BEBULIN BELEODAQ bendamustine hcl BENDEKA BENEFIX BENLYSTA BERINERT BESPONSA BETASERON BETHKIS bevacizumab bexarotene BICNU BIKTARVY BIVIGAM bleo 15k bleomycin sulfate BLINCYTO bortezomib BOSULIF BOTOX BRAFTOVI BRINEURA BUPHENYL busulfan BUSULFEX CABLIVI CABOMETYX CALQUENCE CAMPTOSAR capecitabine CAPRELSA CARBAGLU carboplatin CARIMUNE NF NANOFILTERED carmustine CAYSTON CELLCEPT CEPROTIN CERDELGA CEREZYME CETROTIDE CHOLBAM chorionic gonadotropin 1

2 Specialty Medications CIMDUO CIMZIA CINQAIR CINRYZE cisplatin cladribine clofarabine CLOLAR COAGADEX COMBIVIR COMETRIQ COMPLERA COPAXONE COPEGUS COPIKTRA CORIFACT COSENTYX (2 SYRINGES)* COSENTYX PEN (2 PENS)* COSENTYX PEN* COSENTYX SYRINGE* COSMEGEN COTELLIC CRIXIVAN CRYSVITA CUPRIMINE cyclophosphamide cyclosporine cyclosporine modified CYRAMZA CYSTAGON CYSTARAN cytarabine CYTOGAM dacarbazine DACOGEN dactinomycin DAKLINZA dalfampridine er DARZALEX daunorubicin hcl DAURISMO decitabine deferasirox DELSTRIGO DEPEN DEPOCYT DESCOVY dexrazoxane DEXTENZA didanosine DOCEFREZ docetaxel DOPTELET DOXIL doxorubicin hcl doxorubicin hcl liposome DUPIXENT DUROLANE DYSPORT EDURANT efavirenz EGRIFTA ELAPRASE ELELYSO ELIGARD ELLENCE ELOCTATE ELZONRIS EMFLAZA EMPLICITI EMTRIVA ENBREL ENBREL MINI ENBREL SURECLICK enoxaparin sodium entecavir ENTYVIO ENVARSUS XR EPCLUSA EPIDIOLEX epirubicin hcl EPIVIR EPIVIR HBV EPOGEN epoprostenol sodium EPZICOM ERBITUX ERIVEDGE ERLEADA ERWINAZE ESBRIET ETHYOL ETOPOPHOS etoposide EUFLEXXA EVOMELA EVOTAZ EXJADE EXONDYS 51 EXTAVIA EYLEA FABRAZYME FARYDAK FASENRA FASLODEX FEIBA NF FERRIPROX FIBRYGA FIRAZYR FIRDAPSE FIRMAGON FLEBOGAMMA DIF FLOLAN floxuridine fludarabine phosphate fluorouracil FOLLISTIM AQ FOLOTYN fondaparinux sodium FORTEO fosamprenavir calcium FRAGMIN FULPHILA HUMIRA(CF) PEN PSOR-UV- FUSILEV ADOL HS FUZEON HYALGAN GALAFOLD HYCAMTIN GAMASTAN hydroxyprogesterone GAMASTAN S-D caproate GAMIFANT HYMOVIS GAMMAGARD LIQUID HYPERRHO S-D GAMMAGARD S-D HYQVIA GAMMAKED IBRANCE GAMMAPLEX ICLUSIG GAMUNEX-C IDAMYCIN PFS GANIRELIX ACETATE idarubicin hcl ganirelix acetate IDELVION GATTEX IDHIFA GAZYVA IFEX gel-one ifosfamide GELSYN-3 ILARIS gemcitabine hcl ILUMYA GEMZAR imatinib mesylate gengraf IMBRUVICA GENOTROPIN IMFINZI genvisc 850 IMLYGIC GENVOYA INBRIJA GILENYA* INCRELEX GILOTRIF INFLECTRA GLASSIA INFUGEM glatiramer acetate INGREZZA glatopa INLYTA GLEEVEC INTELENCE GLEOSTINE INTRON A GONAL-F INVIRASE GONAL-F RFF IRESSA GONAL-F RFF REDI-JECT irinotecan hcl GRANIX ISENTRESS H.P. ACTHAR ISENTRESS HD HAEGARDA ISTODAX HALAVEN IXEMPRA HARVONI IXINITY HELIXATE FS JAKAFI HEMLIBRA JETREA HEMOFIL M JEVTANA HEPSERA JIVI HERCEPTIN JULUCA HETLIOZ JUXTAPID HIZENTRA JYNARQUE HUMATE-P KADCYLA HUMATROPE KALBITOR HUMIRA KALETRA HUMIRA PEDIATRIC KALYDECO CROHN'S KANUMA HUMIRA PEN KEPIVANCE HUMIRA PEN CROHN'S- KEVEYIS UC-HS KEVZARA* HUMIRA PEN PSOR- KEYTRUDA UVEITS-ADOL HS KHAPZORY HUMIRA(CF) KINERET HUMIRA(CF) PEDIATRIC KISQALI CROHN'S KISQALI FEMARA CO-PACK HUMIRA(CF) PEN KITABIS PAK HUMIRA(CF) PEN KOATE CROHN'S-UC-HS KOGENATE FS 2

3 Specialty Medications KORLYM KOVALTRY KRYSTEXXA KUVAN KYMRIAH KYNAMRO KYPROLIS lamivudine lamivudine hbv lamivudine-zidovudine LARTRUVO ledipasvir-sofosbuvir LEMTRADA LENVIMA LETAIRIS LEUKINE leuprolide acetate levoleucovorin calcium LEXIVA LIBTAYO lipodox lipodox 50 LONSURF lopinavir-ritonavir LORBRENA LOVENOX LUCENTIS LUMIZYME LUMOXITI LUPANETA PACK LUPRON DEPOT LUPRON DEPOT-PED LUXTURNA LYNPARZA MACUGEN MAKENA MARQIBO MATULANE MAVYRET MAYZENT MEKINIST MEKTOVI melphalan hcl MENOPUR MEPSEVII mercaptopurine mesna MESNEX miglustat MIRCERA mitomycin mitomycin-sterile water mitoxantrone hcl moderiba MONOCLATE-P MONONINE MONOVISC MOZOBIL MULPLETA MUSTARGEN MUTAMYCIN MYALEPT mycophenolate mofetil mycophenolic acid MYFORTIC MYLOTARG MYOBLOC NAGLAZYME NATPARA NAVELBINE NEORAL NERLYNX NEULASTA NEUPOGEN nevirapine nevirapine er NEXAVAR NILANDRON nilutamide NINLARO NIPENT NITYR NIVESTYM NORDITROPIN FLEXPRO NORTHERA NORVIR NOVAREL NOVOEIGHT NOVOSEVEN RT NPLATE NUCALA NULOJIX NUTROPIN AQ NUTROPIN AQ NUSPIN NUWIQ OBIZUR OCALIVA OCREVUS OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV OLUMIANT OLYSIO OMNITROPE ONCASPAR ONIVYDE ONPATTRO OPDIVO OPSUMIT ORENCIA ORENCIA CLICKJECT ORENITRAM ER ORFADIN ORKAMBI ORTHOVISC OTEZLA OVIDREL oxaliplatin OXERVATE OZURDEX paclitaxel PALYNZIQ PANHEMATIN PANZYGA PARSABIV PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PERJETA PHOTOFRIN PIFELTRO PLEGRIDY PLEGRIDY PEN POMALYST PORTRAZZA POTELIGEO PRALUENT PEN PRALUENT SYRINGE PREGNYL PREVYMIS PREZCOBIX PREZISTA PRIALT PRIVIGEN PROCRIT PROCYSBI PROFILNINE PROGRAF PROLASTIN C PROLEUKIN PROLIA PROMACTA PULMOZYME PURIXAN RADICAVA RAPAMUNE RAVICTI REBETOL REBIF REBIF REBIDOSE REBINYN RECLAST RECOMBINATE REMICADE REMODULIN RENFLEXIS REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR RETACRIT RETISERT RETROVIR REVATIO REVCOVI REVLIMID REYATAZ RIASTAP ribasphere RIBASPHERE RIBAPAK RIBATAB ribavirin ritonavir RITUXAN RITUXAN HYCELA RIXUBIS romidepsin RUBRACA RUCONEST RYDAPT SABRIL SAIZEN SAIZEN-SAIZENPREP SAMSCA SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR DEPOT SELZENTRY SEROSTIM SIGNIFOR SIGNIFOR LAR sildenafil sildenafil citrate SILIQ SIMPONI SIMPONI ARIA sirolimus sodium phenylbutyrate sofosbuvir-velpatasvir SOLIRIS SOMATULINE DEPOT SOMAVERT SOVALDI SPINRAZA SPRAVATO SPRYCEL stavudine STELARA STIVARGA STRENSIQ STRIBILD SUBLOCADE SUCRAID supartz fx SUPPRELIN LA SUSTIVA SUTENT SYLATRON SYLVANT SYMDEKO SYMFI SYMFI LO SYMTUZA SYNAGIS SYNRIBO SYNVISC SYNVISC-ONE SYPRINE TABLOID tacrolimus tadalafil 20 mg tablet (generic for adcirca) TAFINLAR TAGRISSO TAKHZYRO 3

4 Specialty Medications TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (2 PACK) TALTZ AUTOINJECTOR (3 PACK) TALTZ SYRINGE TALTZ SYRINGE (2 PACK) TALTZ SYRINGE (3 PACK) TALZENNA TARCEVA TARGRETIN TASIGNA TAVALISSE TAXOTERE TECENTRIQ TECFIDERA TECHNIVIE TEGSEDI TEMODAR temozolomide temsirolimus teniposide tenofovir disoproxil fumarate TEPADINA tetrabenazine THALOMID THIOLA thiotepa THROMBATE III THYROGEN TIBSOVO TIVICAY TOBI TOBI PODHALER tobramycin toposar topotecan hcl TORISEL TOTECT TRACLEER TREANDA TRELSTAR TREMFYA treprostinil tretinoin TRETTEN trientine hcl TRIPTODUR TRISENOX TRIUMEQ trivisc TRIZIVIR TROGARZO TRUVADA TYBOST TYKERB TYMLOS TYSABRI TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA UDENYCA ULTOMIRIS UNITUXIN UPTRAVI VALCHLOR VANTAS VECTIBIX VELCADE VELETRI VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK VENTAVIS VERZENIO VIDAZA VIDEX VIDEX EC VIEKIRA PAK VIEKIRA XR vigabatrin vigadrone VIMIZIM vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD visco-3 VISUDYNE VITEKTA VITRAKVI VIVITROL VIZIMPRO VONVENDI VOSEVI VOTRIENT VPRIV VYXEOS WILATE WINRHO SDF XALKORI XELJANZ XR* XELJANZ* XELODA XENAZINE XEOMIN XERMELO XGEVA XIAFLEX XOLAIR XOSPATA XTANDI XURIDEN XYNTHA XYNTHA SOLOFUSE XYREM YERVOY YESCARTA YONDELIS YONSA YUTIQ ZALTRAP ZANOSAR ZARXIO ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZEPATIER ZERIT ZEVALIN ZIAGEN zidovudine ZINBRYTA ZINECARD ZOLADEX zoledronic acid ZOLINZA ZOMACTON ZOMETA ZORBTIVE ZORTRESS ZYDELIG ZYKADIA ZYTIGA 4

5 DISCRIMINATION IS AGAINST THE LAW Final Rule Under Section 1557 for Nondiscrimination and Accessibility Requirements We comply with applicable Federal civil rights laws and the Minnesota Human Rights Act. We do not discriminate against, exclude, or treat people differently or deny any person the full and equal enjoyment of the goods, services, facilities, privileges, advantages, and accommodations of a place of public accommodation because of race, color, creed, religion, national origin, marital status, age, disability, sexual orientation or sex. We provide free aids and services to help people communicate effectively with us, such as: Qualified sign language interpreters, call TTY for hearing and language impaired, dial 711. Qualified spoken language interpreters, for people whose preferred language is not English, call Written information in other languages and formats (such as large print, audio and accessible electronic formats), call If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, creed, religion, national origin, marital status, age, disability, sexual orientation or sex, you can file a grievance with your facility in person or by mail, fax or . The contacts listed below will help you. For a copy of our grievance procedure, go to: ClearScript SM Fairview Pharmacy Services Corporate Office, 711 Kasota Ave. S.E., Minneapolis, MN Phone: Fax: dept-pharm-compliance@fairview.org You can also file a non-discrimination complaint with the U.S. Department of Health and Human Services and/or Minnesota Department of Human Rights: U.S. Department of Health and Human Services, Office for Civil Rights: Electronically through the Office for Civil Rights Complaint Portal, available at: By mail at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C By phone: , (TDD). Complaint forms are available at: Minnesota Department of Human Rights: Electronically through the MDHR complaint inquiry form, available at By mail at: Minnesota Department of Human Rights, 625 Robert Street North, Saint Paul, MN By phone: (TTY ) or Toll Free at LANGUAGE SERVICES (TTY: 711) Available 24 Hours ATTENTION: Language assistance services, free of charge, are available to you. Call Somali FIIRO GAAR AH: Hadii aad ku hadasho Soomaali, waaxda luqadaha,qaybta kaalmada adeegyada, waxay idiin hayaan adeeg kharash la aan ah. So wac Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al page 1 of 2

6 Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Arabic ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните Oromo XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ Cambodian Lao ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화해주십시오. French ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le Farsi Karen Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para Italian ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます まで お電話にてご連絡ください German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer SW Rev page 2 of 2