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Blue Cross and Blue Shield of TexasSpecialty Drug Management ListCoverage for Specialty MedicationsThe Specialty Drug Management List is a list of medications that our plans identify as being a specialty medication.Specialty medications are often prescribed to treat complex and/or chronic conditions, such as multiple sclerosis, hepatitis C and rheumatoid arthritis. Thesemedications may have special handling and/or storage needs. Coverage for specialty medications that are FDA approved for self-administration are oftenprovided through your pharmacy benefit plan. Specialty medications that are FDA approved for administration by a health care professional are oftencovered under your medical benefit plan. Some medications on the Specialty Drug Management List may be covered by either the pharmacy or medicalbenefit. So, these medications will appear under both the pharmacy and medical sections. The Specialty Drug Management List is not all inclusive and issubject to change. The listing of the drug on this list does not guarantee coverage. If you have any questions, call the num ber on your member ID card.Drugs Covered Under Your Pharmacy Benefits:Please note: You may need approval before these drugs can be considered for coverage. Your doctor can find request forms at bcbstx.com/provider. Yourdoctor can also call the number on your ID card with any questions about your benefits. Based on the terms of your benefit plan, you may nee d to fill theseprescriptions at an in-network specialty pharmacy to get the most out of your benefits. Call the number on your member ID card to help locate an in-networkspecialty pharmacy near you. BCBSTX members who use oral oncology or hemophilia spec ialty drugs may have other in-network specialty pharmacyoptions.Drugs Covered Under Your Pharmacy Benefit:Drug CategoryRoute ofAdministrationABIRATERONE ACETATECANCER-ORALORACTEMRAAUTOIMMUNESCACTEMRA ACTPENAUTOIMMUNESCACTHARENDOCRINEACTIMMUNELUNG DISORDERSSCADCIRCAPULMONARY HYPERTENSIONORADEMPASPULMONARY AIVAFINITORCANCER-ORALORAFINITOR CER-ORALORALKERANCANCER-ORALORALKINDI SPRINKLECORTICOSTEROIDSORALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMANHEMOPHILIAIVALPHANINE RALORALYQPULMONARY HYPERTENSIONORAMBRISENTANPULMONARY HYPERTENSIONORAMPYRAMULTIPLE SCLEROSISORAPOKYNPARKINSONSCARANESP ALBUMIN FREEBLOOD MODIFIERSARCALYSTAUTOIMMUNESCARIKAYCECYSTIC FIBROSISINAUBAGIOMULTIPLE SCLEROSISORAUSTEDOOTHER NON-CATEGORIZEDORAVONEXMULTIPLE SCLEROSISIMAVONEX PENMULTIPLE SCLEROSISIMAYVAKITCANCER-ORALORIJIJRoute of Administration key: CO Combination, EX External, IJ Injection, IM Intramuscular, IN Inhalation, IO Intraocular, IT Intrathecal, IV Intravenous,IZ Intravitreal, OP Ophthalmic, OR Oral, SC SubcutaneousThis list is subject to change without notice. Product names are the property of their respective owners.The relationship between Blue Cross and Blue Shield of Texas and the specialty pharmacies is that of independent contractors. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, acentral specialty and home delivery pharmacy. Blue Cross and Blue Shield of Texas contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BlueCross and Blue Shield of Texas, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ofAssociation.4220 TX Prime Therapeutics LLC 4/1/21

Blue Cross and Blue Shield of TexasSpecialty Drug Management ListRoute ofAdministrationDrugs Covered Under Your Pharmacy Benefit:Drug CategoryBAFIERTAMMULTIPLE RONMULTIPLE SCLEROSISSCBETHKISCYSTIC FIBROSISINBEXAROTENECANCER-ORALORBOSENTANPULMONARY RALORBRAVELLEFERTILITY & PREGNANCYIJBRONCHITOLCYSTIC FIBROSISINBRONCHITOL TOLERANCE TESTCYSTIC FIBROSISINBRUKINSACANCER-ORALORBUPHENYLENZYME DEFICIENCIESORBYNFEZIA PENENDOCRINESCCABLIVIBLOOD ARBAGLUENZYME DEFICIENCIESORCASODEXCANCER-ORALORCAYSTONCYSTIC FIBROSISINCERDELGAENZYME DEFICIENCIESORCETROTIDEFERTILITY & INTESTINALORCHORIONIC GONADOTROPINFERTILITY & PREGNANCYIMCIMZIAAUTOIMMUNESCCIMZIA STARTER KITAUTOIMMUNESCCLOVIQUEOTHER HILIAIVCOMETRIQCANCER-ORALORCOPAXONEMULTIPLE IVCOSENTYXAUTOIMMUNESCIJRoute of Administration key: CO Combination, EX External, IJ Injection, IM Intramuscular, IN Inhalation, IO Intraocular, IT Intrathecal, IV Intravenous,IZ Intravitreal, OP Ophthalmic, OR Oral, SC SubcutaneousThis list is subject to change without notice. Product names are the property of their respective owners.The relationship between Blue Cross and Blue Shield of Texas and the specialty pharmacies is that of independent contractors. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, acentral specialty and home delivery pharmacy. Blue Cross and Blue Shield of Texas contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BlueCross and Blue Shield of Texas, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ofAssociation.4220 TX Prime Therapeutics LLC 4/1/21

Blue Cross and Blue Shield of TexasSpecialty Drug Management ListDrugs Covered Under Your Pharmacy Benefit:Drug CategoryRoute ofAdministrationCOSENTYX SENSOREADY PENAUTOIMMUNESCCOTELLICCANCER-ORALORCUPRIMINEOTHER ER ITIS CORDALFAMPRIDINE ERMULTIPLE SCLEROSISORDAURISMOCANCER-ORALORDEFERASIROXOTHER NON-CATEGORIZEDORDEFERIPRONEOTHER NON-CATEGORIZEDORDEPEN TITRATABSOTHER NON-CATEGORIZEDORDIMETHYL FUMARATEMULTIPLE SCLEROSISORDIMETHYL FUMARATE STARTERPACKMULTIPLE SCLEROSISORDOJOLVIVITAMINS & SUPPLEMENTSORDOPTELETBLOOD MODIFIERSORDUPIXENTAUTOIMMUNESCEGRIFTAHIVSCEGRIFTA SVHIVSCELIGARDOTHER REL MINIAUTOIMMUNESCENBREL SURECLICKAUTOIMMUNESCENDARIBLOOD TITIS COREPOGENBLOOD ERLOTINIB HYDROCHLORIDECANCER-ORALORESBRIETLUNG LOREVEROLIMUSCANCER-ORALOREVRYSDIOTHER NON-CATEGORIZEDOREXJADEOTHER NON-CATEGORIZEDOREXTAVIAMULTIPLE SCLEROSISSCIJRoute of Administration key: CO Combination, EX External, IJ Injection, IM Intramuscular, IN Inhalation, IO Intraocular, IT Intrathecal, IV Intravenous,IZ Intravitreal, OP Ophthalmic, OR Oral, SC SubcutaneousThis list is subject to change without notice. Product names are the property of their respective owners.The relationship between Blue Cross and Blue Shield of Texas and the specialty pharmacies is that of independent contractors. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, acentral specialty and home delivery pharmacy. Blue Cross and Blue Shield of Texas contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BlueCross and Blue Shield of Texas, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ofAssociation.4220 TX Prime Therapeutics LLC 4/1/21

Blue Cross and Blue Shield of TexasSpecialty Drug Management ListDrugs Covered Under Your Pharmacy Benefit:Drug CategoryRoute -ORALORFASENRA PENLUNG DISORDERSSCFEIBAHEMOPHILIAIVFERRIPROXOTHER NON-CATEGORIZEDORFERRIPROX TWICE-A-DAYOTHER OIMMUNEORFOLLISTIM AQFERTILITY & PREGNANCYSCFORTEOBONE DENSITYSCFULPHILABLOOD MODIFIERSSCGALAFOLDENZYME DEFICIENCIESORGANIRELIX ACETATEFERTILITY & RALORGENOTROPINGROWTH HORMONESSCGENOTROPIN MINIQUICKGROWTH HORMONESSCGILENYAMULTIPLE SCLEROSISORGILOTRIFCANCER-ORALORGLASSIALUNG DISORDERSIVGLATIRAMER ACETATEMULTIPLE SCLEROSISSCGLATOPAMULTIPLE LORGOCOVRIPARKINSONORGONAL-FFERTILITY & PREGNANCYIJGONAL-F RFFFERTILITY & PREGNANCYSCGONAL-F RFF REDIJECTFERTILITY & PREGNANCYSCGRANIXBLOOD MODIFIERSSCHAEGARDAHEMATOLOGICALSCHARVONIHEPATITIS CORHELIXATE FSHEMOPHILIAIVHEMLIBRAHEMOPHILIASCHEMOFIL MHEMOPHILIAIVHUMATE-PHEMOPHILIAIVHUMATROPEGROWTH HORMONESIJHUMATROPE COMBO PACKGROWTH HORMONESIJHUMIRAAUTOIMMUNESCHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACKAUTOIMMUNESCHUMIRA PENAUTOIMMUNESCRoute of Administration key: CO Combination, EX External, IJ Injection, IM Intramuscular, IN Inhalation, IO Intraocular, IT Intrathecal, IV Intravenous,IZ Intravitreal, OP Ophthalmic, OR Oral, SC SubcutaneousThis list is subject to change without notice. Product names are the property of their respective owners.The relationship between Blue Cross and Blue Shield of Texas and the specialty pharmacies is that of independent contractors. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, acentral specialty and home delivery pharmacy. Blue Cross and Blue Shield of Texas contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BlueCross and Blue Shield of Texas, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ofAssociation.4220 TX Prime Therapeutics LLC 4/1/21

Blue Cross and Blue Shield of TexasSpecialty Drug Management ListDrugs Covered Under Your Pharmacy Benefit:Drug CategoryRoute ofAdministrationHUMIRA PEN-CD/UC/HS STARTERAUTOIMMUNESCHUMIRA PEN-PEDIATRIC UC STARTER PACKAUTOIMMUNESCHUMIRA PEN-PS/UV CER-ORALORICATIBANT HEMOPHILIAIVIDHIFACANCER-ORALORIMATINIB ELIFESTYLESCINBRIJAPARKINSONININCRELEXGROWTH HORMONESSCINGREZZAOTHER RALORINREBICCANCER-ORALORINTRON AHEPATITIS PHILIAIVJADENUOTHER NON-CATEGORIZEDORJADENU SPRINKLEOTHER ALYDECOCYSTIC FIBROSISORKESIMPTAMULTIPLE ISQALICANCER-ORALORKISQALI FEMARACANCER-ORALORKITABIS PAKCYSTIC GENATE FSHEMOPHILIAIVKORLYMOTHER NON-CATEGORIZEDORKOSELUGOCANCER-ORALORIJRoute of Administration key: CO Combination, EX External, IJ Injection, IM Intramuscular, IN Inhalation, IO Intraocular, IT Intrathecal, IV Intravenous,IZ Intravitreal, OP Ophthalmic, OR Oral, SC SubcutaneousThis list is subject to change without notice. Product names are the property of their respective owners.The relationship between Blue Cross and Blue Shield of Texas and the specialty pharmacies is that of independent contractors. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, acentral specialty and home delivery pharmacy. Blue Cross and Blue Shield of Texas contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BlueCross and Blue Shield of Texas, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield ofAssociation.4220 TX Prime Therapeutics LLC 4/1/21