Restricted-Use Opioids Form

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval (Extended-Release Opioids)

Blue Cross Blue Shield of North Dakota Updated 05/01/2026 Page 1 of 2 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change

Restricted Use Drug -A Prescription Medication or Drug that may require Prior Approval and/or be subject to a limited dispensing amount.

Key Definitions CE Coverage Exception For Qualified Health Plans (QHP), this is a Non-Formulary drug excluded from coverage. If seeking coverage, a Coverage Exception Form must be submitted for review The coverage exception form can be found on the link below: https://www.myprime.com/content/dam/prime/memberportal/forms/2018/FullyQualified/Other/ALL/BCBSND/CO MMERCIAL/NDIVLDRUG/NDHIMCoverage_Exception.pdf OR https://www.myprime.com/en/coverage-exception-form.html
F Formulary Drug A Brand Name or Generic Prescription Drug that has been determined to be safe, therapeutically effective, high quality, and cost-effective as determined by a committee of Physicians and Pharmacists based on current data. See benefit plan Formulary NF Non- Formulary Drug A Prescription Medication or Drug that is not a Formulary Drug. See benefit plan Formulary PA Prior Approval A drug that requires Prior Approval. Prior authorization form for pharmacy drugs can be found on the link below:
https://www.myprime.com/en/forms/coverage-determination/prior-authorization.html
QHP Qualified Health Plan BlueCare, BlueDirect, BlueEssential, BluePartner, BluePrime and SimplyBlue *Patients who are new to Opioid IR or ER therapy will be allowed to fill for a maximum of a 7-day supply on their first fill. Please contact a Member Services representative for specific coverage information

The following List of Drugs represents the drugs requiring Prior Approval (PA) • This entire list applies to the commercial population. • PA/CE prior authorization form for pharmacy drugs can be found on the link below:
o https://www.myprime.com/en/forms/coverage-determination/prior-authorization.html • Specific criteria must be met before medication is covered under the pharmacy benefit. Unless otherwise noted, if a prior approval is granted, the drug will be allowed at the Formulary benefit level. • Extended-Release Opioids: BCBSND will require Prior Approval for Opioid ER products. Patients that are currently on an extended-release will be allowed continuation of therapy for the same agent. Dispensing limits are currently in place for all opioid ER products

BRAND (generic) DRUG NAME QHP* CONZIP CE, PA fentanyl transdermal patch 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr PA fentanyl transdermal patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr, CE, PA HYDROCODONE CAP ER PA hydrocodone tab ER CE, PA hydromorphone tab ER PA HYSINGLA ER CE, PA MORPHINE SULFATE CAP ER CE, PA morphine sulfate tab ER (generic for MS CONTIN) PA MS CONTIN CE, PA NUCYNTA ER PA OXYCODONE ER CE, PA OXYCONTIN PA OXYMORPHONE ER PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval (Extended-Release Opioids)

Blue Cross Blue Shield of North Dakota Updated 05/01/2026 Page 2 of 2 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change

BRAND (generic) DRUG NAME QHP* TAPENTADOL TAB 50MG, 100MG, 150MG, 200MG, 250MG CE, PA TRAMADOL CAP ER 100MG, 200MG, 300MG CE, PA tramadol tab ER 100mg, 200mg, 300mg PA TRAMADOL TAB ER 100mg, 200mg, 300mg CE, PA XTAMPZA ER CE, PA

Blue Cross Blue Shield of North Dakota 4510 13th Avenue South • Fargo, ND 58121 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association. BND-21-003795A • 7-25

Blue Cross Blue Shield of North Dakota (BCBSND) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, gender identity, sexual orientation or sex. BCBSND does not exclude people or treat them differently because of race, color, national origin, age, disability, gender identity, sexual orientation or sex. BCBSND: • Provides free aids and services to people with disabilities to communicate effectively with us,
such as: written information in other formats (large print, audio, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, please call Member Services at 1-844-363-8457 (toll-free) or through
the North Dakota Relay at 1-800-366-6888 or 711. If you believe BCBSND has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, gender identity, sexual orientation or sex, you can file a grievance with: Civil Rights Coordinator,
4510 13th Ave. S. Fargo, ND 58121, 701-297-1638 or North Dakota Relay at 800-366-6888 or 711, 701-282-1804 (fax), CivilRightsCoordinator@bcbsnd.com (email) (unencrypted emails present a risk.) You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling
1-844-363-8457. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, 200 Independence Ave. S.W. Room 509F, HHH Building, Washington, DC 20201, 800-368-1019 or 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Español (Spanish) – ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia con el idioma. También hay disponibles ayudas y servicios auxiliares adecuados
para proporcionar información en formatos accesibles sin cargo. Llame al 1-844-363-8457
(TTY: 1-800-366-6888 o 711) o hable con su proveedor. Deutsch (German) – ACHTUNG: Wenn Sie Deutsch sprechen, steht Ihnen kostenfreie fremdsprachliche Unterstützung zur Verfügung. Außerdem sind kostenlos entsprechende Hilfsmittel und Dienstleistungen zur Bereitstellung von Informationen in barrierefreien Formaten erhältlich. Rufen Sie 1-844-363-8457 (TTY: 1-800-366-6888 oder 711) an oder sprechen Sie mit Ihrem Anbieter. 中文 (Chinese) – 注意：如果您說中文，我們可以為您提供免費的語言協助服務。亦免費提供適當的輔 助工具和服務，以無障礙格式提供資訊。請撥打 1-844-363-8457（聽障服務專線
TTY：1-800-366-6888 或 711）或與您的醫療服務提供者討論。 Oromoo (Oromo) – XIYYEEFFANNOO: Afaan Oromoo dubbattu yoo ta’e, tajaajilli gargaarsa afaan hiikuu kaffaltii malee ni argama. Gargaarsi dabalataa gargaaraadhaaf tajaajilli sirrii ta’ee fi odeeffannoo bifa dhaqqabamaa ta’een kennuunis bilisaan ni argama. Bilbili 1-844-363-8457
(TTY: 1-800-366-6888 or 711) ykn dhiyeessaa kee waliin haasa’i. Tiếng Việt (Vietnamese) – CHÚ Ý: Nếu quý vị nói Tiếng Việt, có sẵn các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Chúng tôi cũng cung cấp miễn phí các dịch vụ và hỗ trợ bổ sung thích
hợp để cung cấp thông tin ở các định dạng dễ tiếp cận. Xin gọi 1-844-363-8457
(TTY: 1-800-366-6888 hoặc 711) hoặc nói chuyện với nhà cung cấp của quý vị.

Ikirundi (Bantu – Kirundi) – Wiyubare: Nimba uvuga Ikirundi, wemerewe ubufasha bwo kuronka ururimi ku buntu. Wemerewe kandi ubufasha bukwiye bw’inyongera na serivisi vyo gutanga amakuru mu buryo bworoshe ku buntu. Hamagara kuri 1-844-363-8457 (TTY: 1-800-366-6888 canke 711) canke uvugane n’ujejwe kugufasha. (Arabic)اﻟﻌرﺑﯾﺔ – ﺗﻧﺑﯾﮫ: إذا ﻛﻧت ﺗﺗﺣدث اﻟﻌرﺑﯾﺔ، ﻓﺗﺗوﻓر ﻟك ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ اﻟﻣﺟﺎﻧﯾﺔ. ﺗﺗوﻓر أﯾﺿًﺎ وﺳﺎﺋل وﺧدﻣﺎت إﺿﺎﻓﯾﺔ ﻣﻧﺎﺳﺑﺔ ﻟﺗﻘدﯾم اﻟﻣﻌﻠوﻣﺎت ﺑﺗﻧﺳﯾﻘﺎت ﺳﮭﻠﺔ اﻻﺳﺗﺧدام ﻣن دون أي ﺗﻛﻠﻔﺔ. اﺗﺻل ﻋﻠﻰ اﻟرﻗم: 1-844-363-8457 )اﻟﮭﺎﺗف اﻟﻧﺻﻲ:
1-800-366-6888 أو 711 ( أو ﺗﺣدث إﻟﻰ ﻣﻘدم اﻟرﻋﺎﯾﺔ اﻟﻣﺗﺎﺑﻊ ﻟك. Kiswahili (Swahili) – ZINGATIA: Ikiwa unazungumza Kiswahili, huduma za msaada wa lugha bila malipo zinapatikana kwa ajili yako. Vifaa na huduma saidizi zinazofaa ili kutoa taarifa katika miundo inayoweza kufikiwa pia hupatikana bila malipo. Piga simu 1-844-363-8457 (TTY: 1-800-366-6888 au 711) au zungumza na mtoa huduma wako. Русский (Russian) – ВНИМАНИЕ! Если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Также предоставляется дополнительная бесплатная помощь и услуги отображения информации в доступных форматах. Позвоните по телефону
1-844-363-8457 (TTY: 1-800-366-6888 или 711) или обратитесь к своему поставщику услуг. 日本語 (Japanese) – お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いた だけます。情報を利用可能な形式で提供するための適切な補助具やサービスも無料でご利用いただけま す。1-844-363-8457（TTY：1-800-366-6888 または 711）にお電話いただくか、医療提供者にご相談くださ い。 नेपाली (Nepali) – (यान *दनुहोस्: तपा3 नेपाली भाषा बो7नु89छ भने तपा3का लािग िनःशु7क भाषा सहायता सेवाहA उपलCध छन्। प8ँचयोHय ढाँचाहAमा जानकारी Mदान गनN उपयुO सहायक Mिविध र सेवाहA पिन िनःशु7क उपलCध छन्।
1-844-363-8457 (TTY: 1-800-366-6888 वा 711) मा कल गनुNहोस् वा आ^नो Mदायकसँग कुरा गनुNहोस्। Français (French) – ATTENTION : Si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Vous pouvez aussi bénéficier gratuitement de l’accès à des outils
et services auxiliaires appropriés dans des formats accessibles. Appelez le 1-844-363-8457
(ATS : 1-800-366-6888 ou 711) ou adressez-vous à votre fournisseur. 한국어 (Korean) – 주의: 한국어를 사용하시는 경우, 무료 언어 지원 서비스가 제공됩니다. 접근 가능한 형식으로 정보를 제공하는 적절한 보조 수단 및 서비스도 무료로 이용하실 수 있습니다.
1-844-363-8457(TTY: 1-800-366-6888 또는 711)번으로 전화하거나 담당 의료 서비스 제공자와 상의하십시오. Tagalog (Tagalog) – PAUNAWA: Kung nagsasalita kayo ng Tagalog, mayroong kayong magagamit na libreng tulong na mga serbisyo sa wika. Mayroon ding mga angkop na auxiliary na tulong at serbisyo para magbigay ng impormasyon sa mga naa-access na format na makukuha ng walang singil. Tumawag sa 1-844-363-8457 (TTY: 1-800-366-6888 o 711) o makipag-usap sa iyong provider. Norsk (Norwegian) – OBS: Hvis du snakker norsk, er gratis språkhjelp tilgjengelig for deg.
Passende ytterligere hjelpemidler og tjenester for å oppgi informasjon i tilgjengelige formater
er også tilgjengelig kostnadsfritt. Ring 1-844-363-8457 (TTY: 1-800-366-6888 eller 711) eller
snakk med leverandøren din. Diné (Navajo) – YÁʼÁTʼÉÉH NITSÁHÁKEES: Díí Diné bizaad bee yániłtiʼgo, tʼáá íiyisí tʼáá bee yáhootʼééł dóó baa áháyáʼ átʼé. Tʼáá jííkʼehígíí bee naʼáchʼąąʼ holneʼ dóó tʼáá shikaadééʼ danilè́è́ʼígíí tʼáá jííkʼehgo bee hólǫ́, dóó tʼáá íiyisí doo béésh bee hadooleeł da. 1-844-363-8457 bee hojiiįʼ
(TTY: 1-800-366-6888 dóó 711), dóó naaltsoos nínízingo bee iiná bee nił haneʼígíí nihił chʼá hodoolʼįʼ.