Routes of Administration Self-Administered Drug List Form

Blue Cross Blue Shield of North Dakota Self-Administered Drug List
Reviewed 1/1/2025 Last Revision 1/1/2022
Blue Cross Blue Shield of North Dakota

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An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change

Below is an alphabetical list of self-injectable* drugs that may be covered as part of your pharmacy benefit as an exception to the Routes of Administration Pharmacy Benefit Exclusion List. Some strengths and/or formulations may not be covered. Drugs on this list may be a benefit exclusion. Please refer to your benefit materials for coverage details and the plan website for current information as this publication is subject to change.

*A self-injectable drug is a drug usually entered into a muscle or under the skin with a syringe and needle that can be administered by you or by your caregiver outside the doctor’s office without the need for medical supervision.

Key Definitions MED Medical Drug Prior authorization form for medical drugs can be found on the link below https://www.bcbsnd.com/content/dam/bcbsnd/documents/forms/providers/precertification/outpatient-fillable.pdf

Drug ROA CAVERJECT IC EDEX IC MUSE UR

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