Restricted-Use Prior Approval Drugs Form

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

Blue Cross Blue Shield of North Dakota Updated 5/1/2026 Page 1 of 35 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/COMMERCIAL/NDIVLDRUG/ND HIMCoverage_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. MED Medical Drug A medical benefit drug that requires Prior Approval (Precertification) to be completed by the Medical Pharmacy Solutions Team at Prime Therapeutics. Precertification information for medical drugs can be found on the link below: www.gatewaypa.com/policydisplay/52
MED+ Medical Drug Available on Pharmacy Benefit A drug that requires Prior Approval (Precertification) through the medical benefit prior authorization process but is payable under the pharmacy benefit. Precertification information for medical drugs can be found on the link below: www.bcbsnd.com/providers/policies-precertification/prior-authorization
MEDND Medical Drug review BCBSND A medical benefit drug that requires Prior Approval (Precertification) through BCBSND. Precertification information for medical drugs can be found on the link below: www.bcbsnd.com/providers/policies-precertification/prior-authorization
NF Non-Formulary Drug A Prescription Medication or Drug that is not a Formulary Drug 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 Health Insurance Market Individual, Small Group Formulary and BlueValue Formulary

The following List of Drugs represents the drugs requiring Prior Approval (PA) • This entire list applies to the commercial population. Unless otherwise noted, if a prior approval is granted for a commercial member, the drug will be allowed at the Formulary benefit level. • Both brand name drugs and generic equivalents require Prior Approval. Please see separate documents for drugs requiring Prior Approval, due to a Utilization Management Quantity Limit or a Step Therapy edit.

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

Blue Cross Blue Shield of North Dakota Updated 5/1/2026 Page 2 of 35 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change

BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) ABECMA IDCABTAGENE VICLEUCEL MED Q2055 ABRAXANE PACLITAXEL PROTEIN-BOUND MED J9264 ABRILADA ADALIMUMAB-AFZB
CE, PA

ACTEMRA IV vial (Healthcare Administered) TOCILIZUMAB MED J3262 ACTEMRA prefilled syringe (Self-Administered) TOCILIZUMAB PA

ADAKVEO CRIZANLIZUMAB-TMCA MED J0791 ADALIMUMAB-AATY ADALIMUMAB-AATY CE, PA

ADALIMUMAB-ADAZ ADALIMUMAB-ADAZ
CE, PA

ADALIMUMAB-ADBM ADALIMUMAB-ADBM CE, PA

ADALIMUMAB-FKJP ADALIMUMAB-FKJP
CE, PA

ADALIMUMAB-RYVK ADALIMUMAB-RYVK CE, PA

ADAPALENE/BENZOYL PEROXIDE ADAPALENE-BENZOYL PEROXIDE
CE, PA

ADBRY TRALOKINUMAB-LDRM PA

ADCETRIS BRENTUXIMAB MED J9042 ADCIRCA TADALAFIL PA, CE (Brand only)

ADEMPAS RIOCIGUAT PA

ADLYXIN LIXISENATIDE CE, PA

ADMELOG INSULIN LISPRO CE, PA

ADMELOG SOLOSTAR INSULIN LISPRO CE, PA

ADSTILADRIN NADOFARAGENE FIRADENOV-VNCG MED J9029 ADVAIR DISKUS (Brand only) FLUTICASONE/SALMETEROL CE (Brand only)

ADVATE ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) PA

ADYNOVATE ANTIHEMOPHILIC FACTOR RECOMB PEGYLATED PA

ADZYNMA ADAMTS13 RECOMBINANT-KRHN
MED J7171 AFINITOR/AFINITOR DISPERZ EVEROLIMUS PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) AFREZZA INSULIN REGULAR (HUMAN) INHALATION POWDER CE, PA

AFSTYLA ANTIHEMOPHILIC FACT RCMB SINGLE CHAIN PA

AGAMREE VAMOROLONE CE, PA

AHZANTIVE AFLIBERCEPT-MRBB MED Q5150 AIMOVIG ERENUMAB PA

AJOVY FREMANEZUMAB PA

AKEEGA NIRAPARIB TOSYLATE-ABIRATERONE ACETATE
CE, PA

AKLIEF TRIFAROTENE CE, PA

AKYNZEO IV FOSNETUPITANT/PALONOSETRON MED J1454 ALDURAZYME LARONIDASE SOLN
MED J1931 ALHEMO CONCIZUMAB-MTCI CE, PA

ALECENSA ALECTINIB PA

ALOGLIPTIN ALOGLIPTIN BENZOATE CE, PA

ALOGLIPTIN/METFORMIN HCL ALOGLIPTIN-METFORMIN CE, PA

ALOGLIPTIN/PIOGLITAZONE ALOGLIPTIN-PIOGLITAZONE CE, PA

ALPHANATE ANTIHEMOPHILIC FACTOR/VWF (HUMAN) PA

ALPHANINE SD COAGULATION FACTOR IX PA

ALPROLIX COAGULATION FACTOR IX PA

ALTRENO TRETINOIN CE, PA

ALTUVIIIO ANTIHEMOPHILIC FACT RCMB
PA

ALUNBRIG BRIGATINIB PA

ALVAIZ ELTROMBOPAG CHOLINE CE, PA

ALVESCO CICLESONIDE CE

ALYFTREK VANZACAFTOR-TEZACAFTOR-DEUTIVACAFTOR CE, PA

ALYGLO IMMUNE GLOBULIN (IV)
MED J1552 ALYMSYS BEVACIZUMAB MED Q5126 ALYQ TADALAFIL PA

AMJEVITA
ADALIMUMAB-ATTO CE, PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) AMONDYS-45 CASIMERSEN MED J1426 AMTAGVI LIFILEUCEL MED J9999; C9399 AMVUTTRA VUTRISIRAN MED J0225 ANDEMBRY GARADACIMAB-GXII SOLN AUTO-INJ CE, PA

ANKTIVA NOGAPENDEKIN ALFA INBAK-PMLN MED J9028 ANZUPGO DELGOCITINIB CREAM CE, PA

APHEXDA MOTIXAFORTIDE ACETATE MED J2277 APIDRA INSULIN GLULISINE CE, PA

APIDRA SOLOSTAR INSULIN GLULISINE CE, PA

AQNEURSA LEVACETYLLEUCINE PA

ARAZLO TAZAROTENE PA, CE (Brand only)

ARCALYST RILONACEPT PA

ASCENIV IMMUNE GLOBULIN (HUMAN)-SLRA IV MED J1554 ATRALIN TRETINOIN CE, PA

ATTRUBY ACORAMIDIS HCL CE, PA

AUBAGIO TERIFLUNOMIDE PA, CE (Brand only)

AUCATZYL OBECABTAGENE AUTOLEUCEL MED Q2058 AUGTYRO REPOTRECTINIB
CE, PA

AUKELSO DENOSUMAB-KYQQ MED Q5161 AUSTEDO DEUTETRABENAZINE PA

AUSTEDO XR DEUTETRABENAZINE PA

AVASTIN (cancer indications only require PA) BEVACIZUMAB MED J9035 AVGEMSI GEMCITABINE MED J9184 AVITA TRETINOIN PA

AVMAPKI FAKZYNJA CO-PACK AVUTOMETINIB & DEFACTINIB THERAPY PACK CE, PA

AVONEX INTERFERON β-1a PA

AVSOLA INFLIXIMAB-AXXQ MED Q5121 AVTOZMA IV TOCILIZUMAB-ANOH MED Q5156

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) AVZIVI BEVACIZUMAB-TNJN MED J9999; C9399 AXTLE PEMETREXED DIPOTASSIUM MED J9292 AYVAKIT AVAPRITINIB PA

AZEDRA IOBENGUANE MED A9590 BAFIERTAM MONOMETHYL FUMARATE CE, PA

BALVERSA ERDAFITINIB PA

BASAGLAR KWIKPEN INSULIN GLARGINE CE, PA

BASAGLAR TEMPO PEN INSULIN GLARGINE CE, PA

BAVENCIO AVELUMAB MED J9023 BELRAPZO BENDAMUSTINE MED J9036 BENDEKA BENDAMUSTINE MED J9034 BENEFIX COAGULATION FACTOR IX PA

BENLYSTA (IV) vial (Healthcare Administered) BELIMUMAB MED J0490 BENLYSTA auto-injector or prefilled syringe (Self- Administered) BELIMUMAB PA

BEOVU BROLUCIZUMAB-DBLL MED J0179 BEQVEZ FIDANACOGENE ELAPARVOVEC-DZKT MED J1414 BERINERT C1 ESTERASE INHIBITOR (HUMAN) MED J0597 BESREMI ROPEGINTERFERON ALFA-2B-NJFT PA

BETASERON INTERFERON β-1b PA

BILDYOS DENOSUMAB-NXXP MED Q5162 BILPREVDA DENOSUMAB-NXXP MED Q5162 BIMZELX BIMEKIZUMAB-BKZX CE, PA

BIVIGAM IMMUNE GLOBULIN (HUMAN) IV MED J1556 BIZENGRI ZENOCUTUZUMAB-ZBCO MED J9382 BKEMV ECULIZUMAB-AEEB MED Q5152 BLENREP BELANTAMAB MAFODOTIN-BLMF MED J9999; C9399 BLINCYTO BLINATUMOMAB MED J9039 BOMYNTRA DENOSUMAB-BNHT MED Q5158

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) BOSAYA DENOSUMAB-KYQQ MED Q5161 BOSENTAN BOSENTAN PA

BOSULIF BOSUTINIB CE, PA

BRAFTOVI ENCORAFENIB PA

BRENZAVVY BEXAGLIFLOZIN TAB CE, PA

BREXAFEMME IBREXAFUNGERP CITRATE CE, PA

BREYANZI LISOCABTAGENE MARALEUCEL MED Q2054 BRIUMVI UBLITUXIMAB-XIIY MED J2329 BRUKINSA ZANUBRUTINIB PA

BRYNOVIN SITAGLIPTIN HYDROCHLORIDE ORAL SOLN CE, PA

BYDUREON BCISE EXENATIDE CE, PA

BYDUREON PEN EXENATIDE CE, PA

BYETTA EXENATIDE CE, PA

BYOOVIZ RANIBIZUMAB-NUNA MED Q5124 CABAZITAXEL CABAZITAXEL MED J9064 CABOMETYX CABOZANTINIB PA

CABTREO ADAPALENE-BENZOYL PEROXIDE-CLINDAMYCIN
CE, PA

CALQUENCE ACALABRUTINIB PA

CAMZYOS MAVACAMTEN PA

CAPRELSA VANDETANIB PA

CARBAGLU CARGLUMIC ACID PA, CE (Brand only)

CARVYKTI CILTACABTAGENE AUTOLEUCEL
MED Q2056 CASGEVY EXAGAMGLOGENE AUTOTEMCEL MED J3392 CERDELGA ELIGLUSTAT TARTRATE PA

CEREZYME IMIGLUCERASE MED J1786 CIBINQO ABROCITINIB PA, CE

CIMERLI RANIBIZUMAB-EQRN MED Q5128 CIMZIA lyophilized powder vial (Healthcare Administered) CERTOLIZUMAB MED J0717

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) CIMZIA prefilled syringe (Self-Administered) CERTOLIZUMAB PA

CINQAIR RESLIZUMAB MED J2786 CINRYZE C1 ESTERASE INHIBITOR (HUMAN) MED J0598 COAGADEX COAGULATION FACTOR X PA

COLUMVI GLOFITAMAB-GXBM MED J9286 COMETRIQ CABOZANTINIB S-MAL PA

CONEXXENCE DENOSUMAB-BNHT MED Q5158 COPAXONE GLATIRAMER PA, CE (Brand only)

COPIKTRA DUVELSIB PA

CORLANOR IVABRADINE HCL PA

CORTROPHIN CORTICOTROPIN INJ GEL 80 UN CE, PA

COSELA TRILACICLIB MED J1448 COSENTYX IV (Healthcare Administered) SECUKINUMAB MED J3247 COSENTYX, COSENTYX UNOREADY SECUKINUMAB PA

COTELLIC COBIMETINIB PA

CRENESSITY CRINECERFONT PA

CRESEMBA cap ISAVUCONAZONIUM PA

CRESEMBA injection ISAVUCONAZONIUM SULF FOR IV SOL CE, PA

CRYSVITA BUROSUMAB -TWZA MED J0584 CUTAQUIG IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS MED J1551 CUVITRU IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS MED J1555 CYLTEZO ADALIMUMAB-ADBM
CE, PA

CYRAMZA RAMUCIRUMAB MED J9308 DANYELZA NAXITAMAB-GQGK MED J9348 DANZITEN NILOTINIB TARTRATE CE, PA

DARZALEX DARATUMUMAB MED J9145 DARZALEX FASPRO TARATUMUMAB AND HYALURONIDASE-FIHJ MED J9144 DASATINIB DASATINIB CE, PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) DATROWAY DATOPOTAMAB DERUXTECAN-DLNK MED J9011 DAURISMO GLASDEGIB PA

DAWNZERA DONIDALORSEN SODIUM CE, PA

DENOSUMAB-BNHT DENOSUMAB-BNHT MED J3590; C9399 DENOSUMAB-DSSB DENOSUMAB-DSSB MED J3590; C9399 DEFLAZACORT DEFLAZACORT CE, PA

DEXCOM G5 CGM RECEIVER, TRANSMITTER, SENSOR

PA

DEXCOM G6 CGM RECEIVER, TRANSMITTER, SENSOR

PA

DEXCOM G7 RECEIVER, TRANSMITTER, SENSOR

PA

DIFFERIN ADAPALENE CE, PA

DIHYDROERGOTAMINE NASAL SPRAY DIHYDROERGOTAMINE MESYLATE NASAL SPRAY CE, PA

DOPTELET SPRINKLE AVATROMBOPAG MALEATE CE, PA

DUPIXENT DUPILUMAB PA

DUROLANE SODIUM HYALURONATE MED J7318 DUVYZAT GIVINOSTAT PA

EBGLYSS LEBRIKIZUMAB-LBKZ CE, PA

ECULIZUMAB-AAGH ECULIZUMAB-AAGH MED Q5151 EKTERLY SEBETRALSTAT CE, PA

ELAHERE MIREVETUXIMAB SORAVTANSINE-GYNX MED J9063 ELAPRASE IDURSULFASE MED J1743 ELELYSO TALIGLUCERASE ALFA MED J3060 ELEVIDYS DELANDISTROGENE MOXEPARVOVEC-ROKL MED J1413 ELFABRIO PEGUNIGALSIDASE ALFA-IWXJ MED J2508 ELOCTATE ANTIHEMOPHILIC FACTOR RCMB (BDD-RFVIIIFC) PA

ELREXFIO ELRANATAMAB-BCMM MED J1323 ELTROMBOPAG OLAMINE ELTROMBOPAG OLAMINE PA

ELYXYB ORAL SOLUTION CELECOXIB ORAL SOLUTION CE, PA

ELZONRIS TAGRAXOFUSP MED J9269

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) EMFLAZA DEFLAZACORT CE, PA

EMGALITY GALCANEZUMAB PA

EMPAVELI PEGCETACOPLAN PA

EMRELIS TELISOTUZUMAB VEDOTIN-TLLV MED J9326 ENBREL ETANERCEPT PA

ENCELTO REVAKINAGENE TARORETCEL-LWEY MED J3403 ENDARI GLUTAMINE PA

ENHERTU FAM-TRASTUZUMAB DERUXTECAN-NXKI MED J9358 ENJAYMO SUTIMLIMAB-JOME MED J1302 ENOBY DENOSUMAB-QBDE MED J3590; C9399 ENSACOVE ENSARTINIB HCL CE, PA

ENSPRYNG SATRALIZUMAB-MWGE PA

ENTYVIO IV (Healthcare Administered) VEDOLIZUMAB MED J3380 ENTYVIO pen-injector (Self-administered) VEDOLIZUMAB CE, PA

ENZEEVU AFLIBERCEPT-ABZV MED Q5149 EPCLUSA SOFOSBUVIR-VELPATASVIR 200-50 MG PA

EPCLUSA SOFOSBUVIR-VELPATASVIR 400-100 MG CE, PA

EPCLUSA PELLET PACK SOFOSBUVIR-VELPATASVIR PA

EPIDIOLEX CANNABIDIOL SOLN PA

EPIDUO ADAPALENE-BENZOYL PEROXIDE
CE, PA

EPIDUO FORTE ADAPALENE-BENZOYL PEROXIDE
CE, PA

EPKINLY EPCORITAMAB-BYSP MED J9321 EPYSQLI ECULIZUMAB-AAGH MED Q5151 ERBITUX CETUXIMAB MED J9055 ERIVEDGE VISMODEGIB PA

ERLEADA APALUTAMIDE PA

ESBRIET PIRFENIDONE PA

ESPEROCT ANTIHEMOPHILIC FACTOR RECOMB GLYCOPEG-EXEI PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) EUFLEXXA SODIUM HYALURONATE MED J7323 EVENITY ROMOSOZUMAB MED J3111 EVKEEZA EVINACUMAB-DGNB MED J1305 EVRYSDI RISDIPLAM PA

EXDENSUR DEPEMOKIMAB-ULAA MED J3590; C9399 EXKIVITY MOBOCERTINIB SUCCINATE PA

EXONDYS-51 ETEPLIRSEN MED J1428 EXTAVIA INTERFERON β-1b PA

EYDENZELT AFLIBERCEPT-BOAV MED J3590; C9399 EYLEA AFLIBERCEPT MED J0178 EYLEA HD AFLIBERCEPT MED J0177 FABHALTA IPTACOPAN PA

FABIOR TAZAROTENE PA, CE (Brand only)

FABRAZYME AGALSIDASE BETA MED J0180 FARYDAK PANOBINOSTAT LACTATE CE, PA

FASENRA BENRALIZUMAB MED J0517 FASENRA prefilled autoinjector pen (Self-Administered)
BENRALIZUMAB PA

FERAHEME FURUMOXYTOL
MED Q0138 FIBRYGA FIBRINOGEN CONC PA

FILSPARI SPARSENTAN PA

FIRAZYR ICATIBANT ACETATE PA

FIRDAPSE AMIFAMPRIDINE PA

FLEBOGAMMA IMMUNE GLOBULIN
MED J1572 FLOVENT DISKUS
FLUTICASONE CE

FLOVENT HFA
FLUTICASONE CE

FOLOTYN PRALATREXATE MED J9307 FORTEO TERIPARATIDE PA

FOTIVDA TIVOZANIB HCL PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) FREESTYLE LIBRE READER, SENSOR

PA

FRUZAQLA FRUQUINTINIB CAP
CE, PA

FUROSCIX FUROSEMIDE SUBCUTANEOUS PA

FUSILEV LEVOLEUCOVORIN CALCIUM MED J0641 FYARRO SIROLIMUS-ALBUMIN-BOUND MED J9331 FYLNETRA PEGFILGRASTIM-PBBK MED Q5130 GALAFOLD MIGALASTAT PA

GAMIFANT EMAPALUMAB-LZSG MED J9210 GAMMAGARD LIQUID IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS MED J1569 GAMMAGARD LIQUID ERC IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS MED J1569 GAMMAGARD S/D IMMUNE GLOBULIN (HUMAN) IV MED J1566 GAMMAKED IMMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS MED J1561 GAMMAPLEX IMMUNE GLOBULIN (HUMAN) IV MED J1557 GAMUNEX-C MMUNE GLOBULIN (HUMAN) IV OR SUBCUTANEOUS MED J1561 GAVRETO PRALSETINIB PA

GAZYVA OBINUTUZUMAB MED J9301 GEL-ONE CROSS-LINKED HYALURONATE MED J7326 GELSYN-3 SODIUM HYALURONATE MED J7328 GENOTROPIN SOMATROPIN PA

GENVISC 850 SODIUM HYALURONATE MED J7320 GILENYA FINGOLIMOD PA

GILOTRIF AFATINIB DIMALEATE PA

GIVLAARI GIVOSIRAN SODIUM MED J0223 GLATOPA GLATIRAMER PA, CE (Brand only)

GLEEVEC IMATINIB MESYLATE PA, CE (Brand only)

GOMEKLI MIRDAMETINIB CE, PA

H P ACTHAR GEL CORTICOTROPIN INJ GEL PA

HADLIMA ADALIMUMAB-BWWD SOLN
PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) HAEGARDA C1 ESTERASE INHIBITOR PA

HALAVEN ERIBULIN MESYLATE MED J9179 HARVONI LEDIPASVIR-SOFOSBUVIR PA

HEMGENIX ETRANACOGENE DEZAPARVOVEC-DRLB MED J1411 HEMLIBRA EMICIZUMAB-KXWH PA

HEMOFIL M ANTIHEMOPHILIC FACTOR (HUMAN) PA

HERCEPTIN TRASTUZUMAB MED J9355 HERCEPTIN HYLECTA TRASTUZUMAB & HYALURONIDASE-OYSK MED J9356 HERCESSI TRASTUZUMAB-STRF MED Q5146 HERZUMA TRASTUZUMAB-PKRB MED Q5113 HETLIOZ/ HETLIOZ LQ TASIMELTEON PA

HIZENTRA IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS MED J1559 HULIO ADALIMUMAB-FKJP
CE, PA

HUMALOG JUNIOR KWIKPEN (0.5 UNIT DIAL) INSULIN LISPRO (HUMAN) SOLN CE, PA

HUMALOG MIX, HUMALOG MIX KWIKPEN INSULIN LISPRO PROTAMINE & LISPRO CE, PA

HUMALOG TEMPO INSULIN LISPRO SOLN PEN-INJ W/TRANSMITTER PORT CE, PA

HUMALOG, HUMALOG KWIKPEN (1 UNIT DIAL) INSULIN LISPRO (HUMAN) SOLN CE, PA

HUMATE-P ANTIHEMOPHILIC FACTOR/VWF (HUMAN) PA

HUMATROPE SOMATROPIN CE, PA

HUMIRA ADALIMUMAB PA

HUMULIN N, HUMULIN N KWIKPEN INSULIN NPH (HUMAN) (ISOPHANE) PA

HUMULIN R INSULIN REGULAR (HUMAN) 100 UNIT/ML PA

HYALGAN SODIUM HYALURONATE MED J7321 HYCAMTIN TOPOTECAN PA

HYMOVIS HYALURONAN MED J7322 HYMPAVZI MARSTACIMAB-HNCQ SUBCUTANEOUS SOLN AUTO-INJ PA

HYQVIA IMMUNE GLOBULIN-HYALURONIDASE MED J1575 HYRIMOZ ADALIMUMAB-ADAZ SOLN
CE, PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) IBRANCE PALBOCICLIB PA

IBTROZI TALETRECTINIB ADIPATE CE, PA

ICLUSIG PONATINIB PA

IDACIO ADALIMUMAB-AACF
CE, PA

IDELVION COAGULATION FACTOR IX (RECOMB) (RIX-FP) PA

IDHIFA ENASIDENIB PA

ILARIS CANAKINUMAB MED J0638 ILUMYA TILDRAKIZUMAB MED J3245 IMAAVY NIPOCALIMAB-AAHU MED J9256 IMBRUVICA IBRUTINIB PA

IMDELLTRA
TARLATAMAB-DLLE MED J9026 IMFINZI DURVALUMAB MED J9173 IMJUDO TREMELIMUMAB MED J9347
IMKELDI IMATINIB MESYLATE ORAL SOLN CE, PA

IMULDOSA prefilled autoinjector pen (Self-Administered) USTEKINUMAB-SRLF SOLN AUTO-INJ CE, PA

IMULDOSA IV (Healthcare Administered) USTEKINUMAB-SRLF MED Q5098 INFLECTRA INFLIXIMAB-DYYB MED Q5103 INFLIXIMAB (UNBRANDED) INFLIXIMAB MED J1745 INGREZZA VALBENAZINE PA

INJECTAFER FERRIC CARBOXYMALTOSE MED J1439 INLEXZO GEMCITABINE MED J9183 INLURIYO IMLUNESTRANT TOSYLATE CE, PA

INLYTA AXITINIB PA

INPEFA SOTAGLIFLOZIN CE, PA

INQOVI DECITABINE-CEDAZURIDINE PA

INREBIC FEDRATINIB PA

INSULIN ASPART PROTAMINE/ INSULIN ASPART, INSULIN ASPART PROTAMINE/ INSULIN ASPART FLEXPEN INSULIN ASPART PROTAMINE/ INSULIN ASPART CE, PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) INSULIN ASPART, INSULIN ASPART FLEXPEN, INSULIN ASPART PENFILL INSULIN ASPART CE, PA

INSULIN GLARGINE, INSULIN GLARGINE SOLOSTAR, INSULIN GLARGINE MAX SOLOSTAR INSULIN GLARGINE CE, PA

INSULIN LISPRO JUNIOR KWIKPEN (0.5 UNIT DIAL)
INSULIN LISPRO CE, PA

INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN INSULIN LISPRO PROTAMINE/INSULIN LISPRO CE, PA

INSULIN LISPRO, INSULIN LISPRO KWIKPEN (1 UNIT DIAL) INSULIN LISPRO CE, PA

INVOKAMET/ INVOKAMET XR CANAGLIFLOZIN – METFORMIN CE, PA

INVOKANA CANAGLIFLOZIN CE, PA

IQIRVO ELAFIBRANOR CE, PA

IRESSA GEFITINIB PA

ISTODAX ROMIDEPSIN MED J9319 ISTURISA OSILODROSTAT PHOSPHATE PA

ITOVEBI INAVOLISIB CE, PA

ITVISMA ONASEMNOGENE ABEPARVOVEC-BRVE MED J3590; C9309 IV IMMUNE GLOBULIN INTRAVENOUS IMMUNE GLOBULIN MED J1599; J1566 IVABRADINE IVABRADINE PA

IWILFIN EFLORNITHINE HCL TAB CE, PA

IXEMPRA IXABEPILONE MED J9207 IXINITY COAGULATION FACTOR IX (RECOMBINANT) PA

IZERVAY AVACINCAPTAD PEGOL MED J2782 JAKAFI RUXOLITINIB PA

JASCAYD NERANDOMILAS CE, PA

JAVYGTOR SAPROPTERIN PA

JAYPIRCA PIRTOBRUTINIB CE, PA

JELMYTO MITOMYCIN MED J9281 JEMPERLI DOSTARLIMAB-GXLY MED J9272 JENTADUETO LINAGLIPTIN-METFORMIN CE, PA

JENTADUETO XR LINAGLIPTIN-METFORMIN CE, PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) JEVTANA CABAZITAXEL MED J9043 JIVI ANTIHEMOPHIL FACT RCMB (BDD-RFVIII PEG-AUCL) PA

JOBEVNE BEVACIZUMAB-NWGD MED Q5160 JUBBONTI DENOSUMAB-BBDZ MED Q5136 JYNARQUE TOLVAPTAN PA

KADCYLA ADO-TRASTUZUMAB EMTANSINE MED J9354 KALBITOR ECALLANTIDE MED J1290 KALYDECO GRANULES 5.8 MG IVACAFTOR CE, PA

KALYDECO PAK, TAB, GRANULES 13.4 mg IVACAFTOR PA

KANJINTI TRASTUZUMAB-ANNS MED Q5117 KANUMA SEBELIPASE ALFA MED J2840 KAZANO ALOGLIPTIN-METFORMIN HCL CE, PA

KEBILIDI ELADOCAGENE EXUPARVOVEC-TNEQ MED J3590; C9399 KERENDIA FINERENONE CE, PA

KESIMPTA OFATUMUMAB PA

KEVZARA SARILUMAB PA

KEYTRUDA PEMBROLIZUMAB MED J9271 KEYTRUDA QLEX PEMBROLIZUMAB AND BERAHYALURONIDASE ALFA-PMPH MED J9277 KHAPZORY LEVOLEUCOVORIN SODIUM MED J0642 KIMMTRAK TEBENTAFUSP-TEBN MED J9274 KINERET ANAKINRA PA

KIRSTY INSULIN ASPART-XJHZ CE, PA

KISQALI RIBOCICLIB PA

KISQALI/FEMARA DOSE PAK RIBOCICLIB/LETROZOLE PA

KISUNLA DONANEMAB-AZBT MED J0175 KOATE ANTIHEMOPHILIC FACTOR (HUMAN) PA

KOATE-DVI ANTIHEMOPHILIC FACTOR (HUMAN) PA

KOGENATE FS ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) KOMBIGLYZE XR SAXAGLIPTIN-METFORMIN HCL CE, PA

KORLYM
MIFEPRISTONE (HYPERGLYCEMIA) PA

KOSELUGO SELUMETINIB PA

KOVALTRY ANTIHEMOPHILIC FACTOR RECOMB (RAHF-PFM) PA

KRAZATI ADAGRASIB PA

KRYSTEXXA PEGLOTICASE MED J2507 KUVAN SAPROPTERIN PA, CE (Brand only)

KYMRIAH TISAGENLECLEUCEL MED Q2042 KYPROLIS CARFILZOMIB MED J9047 KYXATA CARBOPLATIN MED J9278 LAMZEDE VELMANASE ALFA-TYCV MED J0217 LANTIDRA DONISLECEL-JUJN MED J3590; C9399 LANTUS, LANTUS SOLOSTAR INSULIN GLARGINE CE, PA

LAPATINIB DITOSYLATE LAPATINIB DITOSYLATE PA

LAZCLUZE LAZERTINIB MESYLATE CE, PA

LEDIPASVIR/SOFOSBUVIR LEDIPASVIR-SOFOSBUVIR PA

LEMTRADA ALEMTUZUMAB MED J0202 LENMELDY ATIDARSAGENE AUTOTEMCEL MED J3391 LENVIMA LENVATINIB MESYLATE PA

LEQEMBI LECANEMAB MED J0174 LEQEMBI IQLK LECANEMAB-IRMB CE, PA

LEQSELVI DEURUXOLITINIB PHOSPHATE CE, PA

LEQVIO INCLISIRAN SODIUM
MED J1306 LETAIRIS AMBRISENTAN PA

L-GLUTAMINE GLUTAMINE (SICKLE CELL) POWD PACK PA

LIBTAYO CEMIPLIMAB-RWLC MED J9119 LIQREV SILDENAFIL CITRATE ORAL SUSP CE, PA

LIRAGLUTIDE LIRAGLUTIDE SOLN PEN-INJECTOR CE, PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) LIVDELZI SELADELPAR LYSINE CE, PA

LONSURF TRIFLURIDINE-TIPIRACIL PA

LOQTORZI TORIPALIMAB-TPZI MED J3263 LORBRENA LORLATINIB PA

LUCENTIS RANIBIZUMAB MED J2778 LUMAKRAS SOTORASIB PA

LUMIZYME ALGLUCOSIDASE ALFA MED J0221 LUMRYZ SODIUM OXYBATEFOR ORAL ER SUSP CE, PA

LUNSUMIO MOSUNETUZUMAB-AXGB MED J9350 LUNSUMIO VELO MOSUNETUZUMAB-AXGB MED J9350 LUPKYNIS VOCLOSPORIN PA

LUTATHERA LUTETIUM LU 177 MED A9513 LUXTURNA VORETIGENE MED J3398 LYFGENIA LOVOTIBEGLOGENE AUTOTEMCEL MED J3394 LYMPHIR DENILEUKIN DIFTITOX-CXDL MED J9161 LYNOZYFIC LINVOSELTAMAB-GCPT MED J9601 LYNPARZA OLAPARIB PA

LYSODREN MITOTANE PA

LYTGOBI FUTIBATINIB PA

LYUMJEV TEMPO PEN INSULIN LISPRO-AABC SOLN PEN-INJ W/TRANSMIT PORT
CE, PA

LYUMJEV, LYUMJEV KWIKPEN INSULIN LISPRO CE, PA

MACI AUTOLOGOUS CULTURED CHONDROCYTE ON COLLAGEN MEMBRANE SHEET MEDND J7330 MARGENZA MARGETUXIMAB-CMKB MED J9353 MATULANE PROCARBAZINE PA

MAVENCLAD CLADRIBINE PA

MAVYRET GLECAPREVIR-PIBRENTASVIR PA

MAYZENT SIPONIMOD PA

MEKINIST TRAMETINIB PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) MEKTOVI BINIMETINIB PA

MEPSEVII VESTRONIDASE ALFA MED J3397 MERILOG, MERILOG SOLOSTAR INSULIN ASPART-SZJJ CE, PA

MIFEPREX MIFEPRISTONE CE, PA

MIGRANAL DIHYDROERGOTAMINE MESYLATE NASAL SPRAY CE, PA

MIPLYFFA ARIMOCLOMOL CITRATE CE, PA

MONJUVI TAFASITAMAB - CXIX MED J9349 MONOFERRIC FERRIC DERISOMALTOSE MED J1437 MONOVISC HYALURON MED J7327 MOUNJARO TIRZEPATIDE PA

MOZOBIL PLERIXAFOR MED J2562 MULPLETA LUSUTROMBOPG PA

MVASI BEVACIZUMAB-AWWB MED Q5107 MYALEPT METRELEPTIN PA

MYFEMBREE RELUGOLIX-ESTRADIOL-NORETHINDRONE ACETATE PA

NAGLAZYME GALSULFASE MED J1458 NEMLUVIO NEMOLIZUMAB-ILTO CE, PA

NERLYNX NERATINIB PA

NESINA ALOGLIPTIN BENZOATE CE, PA

NEXAVAR SORAFENIB PA

NEXLETOL BEMPEDOIC ACID PA

NEXLIZET BEMPEDOIC ACID PA

NEXVIAZYME AVALGLUCOSIDASE ALFA MED J0219 NGENLA SOMATROGON-GHLA SOLUTION PEN-INJECTOR
CE, PA

NIKTIMVO AXATILIMAB-CSFR MED J9038 NILOTINIB NILOTINIB D-TARTRATE CE, PA

NILOTINIB HCL NILOTINIB HCL PA

NINLARO IXAZOMIB PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) NORDITROPIN SOMATROPIN PA

NORTHERA DROXIDOPA CE, PA

NOVOEIGHT ANTIHEMOPHILIC FACT RCMB (BD TRUNC-RFVIII) PA

NOVOSEVEN RT COAGULATION FACTOR VIIA (RECOMB) PA

NOXAFIL packet, suspension POSACONAZOLE packet, suspension PA

NOXAFIL tab POSACONAZOLE tab PA, CE (Brand only)

NPLATE ROMIPLOSTIM MED J2802 NUBEQA DAROLUTAMIDE PA

NUCALA autoinjector or prefilled syringe (Self-Administered) MEPOLIZUMAB PA

NUCALA vial (Healthcare Administered) MEPOLIZUMAB MED J2182 NURTEC RIMEGEPANT SULFATE PA

NUTROPIN/NUTROPIN AQ SOMATROPIN CE, PA

NUWIQ ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,SIM) PA

NYVEPRIA PEGFILGRASTIM-APGF MED Q5122 OCREVUS OCRELIZUMAB MED J2350 OCREVUS ZUNOVO OCRELIZUMAB;HYALURONIDASE-OCSQ MED
J2351 OCTAGAM IMMUNE GLOBULIN (HUMAN) IV MED J1568 ODOMZO SONIDEGIB PA

OFEV NINTEDANIB PA

OGIVRI TRASTUZUMAB-DKST MED Q5114 OGSIVEO NIROGACESTAT HYDROBROMIDE
CE, PA

OJEMDA TOVORAFENIB CE, PA

OJJAARA MOMELOTINIB DIHYDROCHLORIDE CE, PA

OLUMIANT BARICITINIB PA

OMALIZUMAB-IGEC OMALIZUMAB-IGEC MED J3590; C9399 OMISIRGE OMIDUBICEL-ONLV MED J3590; C9399 OMLYCLO OMALIZUMAB-IGEC MED Q5154 OMNIPOD 5 G6 INSULIN INFUSION DISPOSABLE PUMP MED+ N/A

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) OMNIPOD CLASSIC INSULIN INFUSION DISPOSABLE PUMP MED+ N/A OMNIPOD DASH INSULIN INFUSION DISPOSABLE PUMP
MED+ N/A OMNITROPE SOMATROPIN PA

OMVOH auto-injector (Self-Administered) MIRIKIZUMAB-MRKZ
CE, PA

OMVOH IV vial (Healthcare Administered) MIRIKIZUMAB-MRKZ MED J2267 ONCASPAR PEGASPARGASE MED J9266 ONGLYZA SAXAGLIPTIN HCL CE, PA

ONIVYDE IRINOTECAN LIPOSOMAL MED J9205 ONPATTRO PATISIRAN MED J0222 ONTRUZANT TRASTUZUMAB-DTTB MED Q5112 ONUREG AZACITIDINE TAB PA

OPDIVO NIVOLUMAB MED J9299 OPDIVO QVANTIG NIVOLUMAB AND HYALURONIDASE-NVHY MED J9289 OPDUALAG NIVOLUMAB-RELATLIMAB-RMBW MED J9298 OPFOLDA MIGLUSTAT (GAA DEFICIENCY) PA

OSPOMYV DENOSUMAB-DSSB PA Q5159 OPSUMIT MACITENTAN PA

OPSYNVI MACITENTAN-TADALAFIL CE, PA

OPUVIZ AFLIBERCEPT-YSZY MED Q5153 ORENCIA IV vial (Healthcare Administered) ABATACEPT MED J0129 ORENCIA prefilled syringe or auto-injector (Self- Administered) ABATACEPT PA

ORENITRAM TREPROSTINIL PA

ORGOVYX ELEXACAF-TEZACAF-IVACATOR PA

ORIAHNN RELUGOLIX PA

ORILISSA ELAGOLIX PA

ORKAMBI LUMACAFTOR-IVACAFTOR PA

ORLADEYO BEROTRALSTAT CE, PA

ORSERDU ELACESTRANT HYDROCHLORIDE CE, PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) ORTHOVISC HYALURONAN MED J7324 OSENI ALOGLIPTIN-PIOGLITAZONE CE, PA

OSENVELT DENOSUMAB-BMWO MED Q5157 OTEZLA APREMILAST PA

OTEZLA XR APREMILAST ER 24HR PA

OTULFI IV USTEKINUMAB-AAUZ MED Q9999 OTULFI prefilled syringe or auto-injector (Self-Administered) USTEKINUMAB-AAUZ CE, PA

OXERVATE CENEGERMIN-BKBJ PA

OXLUMO LUMASIRAN MED J0224 OZEMPIC SEMAGLUTIDE PA

PACLITAXEL ALBUMIN-BOUND PACLITAXEL ALBUMIN-BOUND MED J9264 PADCEV ENFORTUMAB VEDOTIN-EJFV MED J9177 PALYNZIQ PEGVALIASE-PQPZ PA

PANCREAZE PANCRELIPASE (LIP-PROT-AMYL)
CE, PA

PANZYGA IMMUNE GLOBULIN (HUMAN)-IFAS IV MED J1576 PAPZIMEOS ZOPAPOGENE IMADENOVEC-DRBA MED J3404 PAVBLU AFLIBERCEPT-AYYH MED Q5147 PAZOPANIB PAZOPANIB CE, PA

PEGFILGRASTIM-FPGK PEGFILGRASTIM-FPGK MED Q5127 PEMAZYRE PEMIGATINIB PA

PEMFEXY PEMETREXED MED J9304 PEMRYDI RTU PEMETREXED MED J9324 PENPULIMAB-KCQX PENPULIMAB-KCQX MED J9999; C9399 PERJETA PERTUZUMAB MED J9306 PERTZYE PANCRELIPASE (LIP-PROT-AMYL)
CE, PA

PHESGO PERTUZUMAB – TRASTUZUMAB – HYALURONIDASE – ZZXF MED J9316 PIASKY CROVALIMAB-AKKZ MED J1307

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) PIQRAY ALPELISIB PA

PIRFENIDONE PIRFENIDONE PA

PLEGRIDY PEGINTERFERON BETA-1A PA

PLUVICTO LUTETIUM LU 177 MED A9607
POLIVY POLATUZUMAB MED J9309 POMALYST POMALIDOMIDE PA

POMBILITI CIPAGLUCOSIDASE ALFA-ATGA MED J1203 PONVORY PONESIMOD CE, PA

POSFREA PALONOSETRON MED J2468 POTELIGEO MOGAMULIZUMAB MED J9204 PRALUENT ALIROCUMAB CE, PA

PRIVIGEN IMMUNE GLOBULIN (HUMAN) IV MED J1459 PROCYSBI CYSTEAMINE BITARTRATE CE, PA

PROFILNINE FACTOR IX COMPLEX PA

PROLIA DENOSUMAB MED J0897 PROMACTA ELTROMBOPAG PA

PROVENGE SIPULEUCEL-T MED Q2043 PYZCHIVA IV USTEKINUMAB-TTWE MED Q9997 PYZCHIVA prefilled syringe or auto-injector (Self- Administered) USTEKINUMAB-TTWE CE, PA

PYRUKYND MITAPIVAT PA

QALSODY TOFERSEN MED J1304 QINLOCK RIPRETINIB PA

QFITLA FITUSIRAN SODIUM SUBCUTANEOUS SOLN
CE, PA

QFITLA FITUSIRAN SODIUM SUBCUTANEOUS SOLN AUTO-INJ CE, PA

QTERN DAPAGLIFLOZIN – SAXAGLIPTIN CE, PA

QTERN DAPAGLIFLOZIN – SAXAGLIPTIN CE, PA

QULIPTA ATOGEPANT PA

QUTENZA CAPSAICIN PATCH MED J7336

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) QIVIGY IMMUNE GLOBULIN IV, HUMAN-KTHM MED J1599; C9399 RADICAVA EDARAVONE MED J1301 RADICAVA ORS EDARAVONE PA

REBIF INTERFERON β-1a PA

REBINYN COAGULATION FACTOR IX RECOMB GLYCOPEGYLATED PA

REBLOZYL LUSPATERCEPT-AAMT MED J0896 RECOMBINATE ANTIHEMOPHILIC FACTOR RECOMB (RFVIII) PA

RECORLEV LEVOKETOCONAZOLE CE, PA

RELYVRIO SODIUM PHENYLBUTYRATE-TAURURSODIOL
PA

REMICADE INFLIXIMAB MED J1745 RENFLEXIS INFLIXIMAB-ABDA MED Q5104 REPATHA EVOLOCUMAB PA

RETEVMO SELPERCATINIB PA

RETHYMIC ALLOGENEIC PROCESSED THYMUS TISSUE-AGDC MED J3590; C9399 RETIN-A, RETIN-A MICRO TRETINOIN PA, CE (Brand only)

REVATIO SILDENAFIL PA, CE (Brand only)

REVCOVI ELAPEADEMASE-LVLR MED J3590; C9399 REVLIMID LENALIDOMIDE PA

REVUFORJ REVUMENIB CITRATE CE, PA

REYVOW LASMIDITAN SUCCINATE PA

REZLIDHIA OLUTASIDENIB PA

REZUROCK BELUMOSUDIL MESYLATE
PA

REZVOGLAR KWIKPEN INSULIN GLARGINE-AGLR SOLN PEN-INJECTOR CE, PA

RHAPSIDO REMIBRUTINIB PA

RIABNI RITUXIMAB-ARRX MED Q5123 RIASTAP FIBRINOGEN CONC (HUMAN) PA

RINVOQ UPADACITINIB PA

RINVOQ LQ UPADACITINIB CE, PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) RITUXAN RITUXIMAB MED J9312 RITUXAN HYCELA RITUXIMAB-HYALURONIDASE MED J9311 RIXUBIS COAGULATION FACTOR IX (RECOMBINANT) PA

ROCTAVIAN VALOCTOCOGENE ROXAPARVOVEC-RVOX MED J1412 ROLVEDON EFLAPEGRASTIM-XNST MED J1449 ROMIDEPSIN ROMIDEPSIN MED J9318 ROMVIMZA VIMSELTINIB CE, PA

ROZLYTREK ENTRECTINIB PA

RUBRACA RUCAPARIB CE, PA

RUCONEST C1 ESTERASE INHIBITOR (RECOMBINANT) MED J0596 RUXIENCE RITUXIMAB-PVVR MED Q5119 RUZURGI AMIFAMPRIDINE PA

RYBELSUS SEMAGLUTIDE PA

RYBREVANT AMIVANTAMAB-VMJW MED J9061 RYBREVANT FASPRO AMIVANTAMAB AND HYALURONIDASE-LPUJ MED J9999; C9399 RYDAPT MIDOSTAURIN PA

RYLAZE ASPARAGINASE ERWINIA CHRYS MED J9021 RYONCIL REMESTEMCEL-L-RKND MED J3402 RYPLAZIM PLASMINOGEN, HUMAN-TVMH MED J2998 RYSTIGGO ROZANOLIXIZUMAB-NOLI MED J9333 RYTELO IMETELSTAT MED J0870 RYZNEUTA EFBEMALENOGRASTIM ALFA-VUXW
MED J9361 SAIZEN SOMATROPIN CE, PA

SAIZENPREP RECONSTITUTIONKIT SOMATROPIN CE, PA

SAJAZIR ICATIBANT ACETATE PA

SAMSCA TOLVAPTAN PA

SAPHNELO ANIFROLUMAB-FNIA MED J0491 SAPROPTERIN DIHYDROCHLORIDE SAPROPTERIN DIHYDROCHLORIDE PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) SARCLISA ISATUXIMAB-IRFC MED J9227 SCENESSE AFAMELANOTIDE MED J7352 SCEMBLIX ASCIMINIB HCL PA

SEGLUROMET ERTUGLIFLOZIN – METFORMIN CE, PA

SELARSDI IV USTEKINUMAB-AEKN MED Q9998 SELARSDI prefilled syringe or auto-injector (Self- Administered) USTEKINUMAB-AEKN CE, PA

SEMGLEE (ONLY NDCs 49502-0196-71, 49502-0196-75, 49502-0195-80) INSULIN GLARGINE CE, PA

SENSIPAR CINACALCET PA, CE (Brand only)

SEPHIENCE SEPIAPTERIN POWDER PACKET CE, PA

SEROSTIM SOMATROPIN CE, PA

SEVENFACT COAGULATION FACTOR VIIA (RECOM)-JNCW PA

SILIQ BRODALUMAB CE, PA

SIMLANDI ADALIMUMAB-RYVK PA

SIMPONI (Self-Administered) GOLIMUMAB PA

SIMPONI ARIA (Healthcare Administered) GOLIMUMAB MED J1602 SITAGLIPTIN/METFORMIN HYDROCHLORIDE SITAGLIPTIN FREE BASE-METFORMIN HCL CE, PA

SKYRIZI IV vial (Healthcare Administered) RISANKIZUMAB-RZAA MED J2327 SKYRIZI prefilled syringe or cartridge (Self-Administered) RISANKIZUMAB-RZAA PA

SKYSONA ELIVALDOGENE AUTOTEMCEL MED J3387 SKYTROFA LONAPEGSOMATROPIN-TCGD PA

SOFOSBUVIR/VELPATASVIR SOFOSBUVIR-VELPATASVIR PA

SOGROYA SOMAPACITAN-BECO SOLUTION PEN-INJECTOR
CE, PA

SOHONOS PALOVAROTENE PA

SOLIRIS ECULIZUMAB MED J1299 SOTYKTU DEUCRAVACITINIB CE, PA

SOVALDI SOFOSBUVIR PA

SPEVIGO SPESOLIMAB-SBZO SUBCUTANEOUS SOLN PREF SYR PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) SPEVIGO IV SPESOLIMAB MED J1747 SPINRAZA NUSINERSEN MED J2326 SPRYCEL DASATINIB PA

STARJEMZA prefilled syringe (Self-Administered) USTEKINUMAB-HMNY CE, PA

STARJEMZA IV USTEKINUMAB-HMNY MED J3590; C9399 STEGLATRO ERTUGLIFLOZIN L-PYROGLUTAMIC ACID CE, PA

STEGLUJAN ERTUGLIFLOZIN – SITAGLIPTIN CE, PA

STELARA IV vial (Healthcare Administered) USTEKINUMAB MED J3358 STELARA prefilled syringe (Self-Administered) USTEKINUMAB PA

STEQEYMA IV vial (Healthcare Administered) USTEKINUMAB-STBA MED Q5099 STEQEYMA prefilled syringe (Self-Administered) USTEKINUMAB-STBA CE, PA

STIMUFEND PEGFILGRASTIM-FPGK MED Q5127 STIVARGA REGORAFENIB PA

STOBOCLO DENOSUMAB-BMWO MED Q5157 STRENSIQ ASFOTASE ALFA PA

SUNOSI SOLRIAMFETOL HCL PA

SUPARTZ FX SODIUM HYALURONATE MED J7321 SUSTOL GRANISETRON EXTENDED RELEASE MED J1627 SUSVIMO RANIBIZUMAB MED J2779 SUTENT SUNITINIB PA

SYFOVRE PEGCETACOPLAN MED J2781 SYLATRON PEGINTERFERON ALFA-2B PA

SYLVANT SILTUXIMAB MED J2860 SYMDEKO TEZACAFTOR-IVACAFTOR CE, PA

SYNAGIS PALIVIZUMAB IM SOLUTION MED 90378 SYNOJOYNT SODIUM HYALURONATE MED J7331 SYNRIBO OMACETAXINE MEPESUCCINATE MED J9262 SYNVISC HYLAN INTRA-ARTICULAR MED J7325

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) SYNVISC-ONE HYLAN INTRA-ARTICULAR MED J7325 TABRECTA CAPMATINIB PA

TADLIQ TADALAFIL CE, PA

TAFINLAR
DABRAFENIB
PA

TAGRISSO OSIMERTINIB PA

TAKHZYRO LANADELUMAB PA

TALTZ IXEKIZUMAB CE, PA

TALVEY TALQUETAMAB-TGVS MED J3055 TALZENNA TALAZOPARIB PA

TARCEVA ERLOTINIB PA

TARGRETIN BEXAROTENE PA, CE (Brand only)

TARPEYO BUDESONIDE DR CE, PA

TASCENSO ODT FINGOLIMOD LAURYL CE, PA

TASIGNA NILOTINIB PA

TASIMELTEON TASIMELTEON PA

TAVALISSE FOSTAMATINIB PA

TAZORAC TAZAROTENE PA, CE (Brand only)

TAZVERIK TAZEMETOSTAT PA

TECARTUS BREXUCABTAGENE AUTOLEUCEL MED Q2053 TECELRA AFAMITRESGENE AUTOLEUCEL MED Q2057 TECENTRIQ ATEZOLIZUMAB MED J9022 TECENTRIQ HYBREZA ATEZOLIZUMAB and HYALURONIDASE-TQJS MED J9024 TECFIDERA DIMETHYL FUMARATE PA, CE (Brand only)

TECVAYLI TECLISTAMAB-CQYV MED J9380 TEGSEDI INOTERSEN PA

TEMODAR TEMOZOLOMIDE PA, CE (Brand only)

TEPEZZA TEPROTUMUMAB-TRBW MED J3241 TEPMETKO TEPOTINIB PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) TERIPARATIDE TERIPARATIDE (RECOMBINANT)
PA

TEVIMBRA TISLELIZUMAB-JSGR MED J9329 TEZSPIRE (Healthcare Administered) TEZEPELUMAB-EKKO MED J2356 TEZSPIRE (Self-Administered) TEZEPELUMAB-EKKO PA

THALOMID THALIDOMIDE PA

TIBSOVO IVOSIDENIB PA

TIVDAK TISOTUMAB VEDOTIN TFTV MED J9273 TOCILIZUMAB-AAZG TOCILIZUMAB-AAZG MED Q5135 TOFIDENCE TOCILIZUMAB-BAVI MED Q5133 TOLVAPTAN TOLVAPTAN CE, PA

TRACLEER BOSENTAN PA

TRADJENTA LINAGLIPTIN CE, PA

TRAZIMERA TRASTUZUMAB-QYYP MED Q5116 TREANDA BENDAMUSTINE MED J9033 TREMFYA GUSELKUMAB PA

TREMFYA IV GUSELKUMAB MED J1628 TRETINOIN MICROSPHERE TRETINOIN MICROSPHERE GEL CE, PA

TRIKAFTA ELEXACAFTOR/ TEZECAFTOR/ IVACAFTOR AND IVACAFTOR PA

TRILURON SODIUM HYALURONATE MED J7332 TRIVISC SODIUM HYALURONATE MED J7329 TRODELVY SACITUZUMAB MED J9317 TRUDHESA DIHYDROERGOTAMINE MESYLATE CE, PA

TRULICITY DULAGLUTIDE PA

TRUQAP CAPIVASERTIB
CE, PA

TRUSELTIQ INFIGRATINIB PA

TRUXIMA RITUXUMAB-ABBS MED Q5115 TRYNGOLZA OLEZARSEN SOD SOLN AUTO-INJ PA

TUKYSA TUCATINIB PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) TURALIO PXIDARTINIB PA

TWYNEO TRETINOIN-BENZOYL PEROXIDE CE, PA

TYENNE TOCILIZUMAB-AAZG CE, PA

TYENNE IV TOCILIZUMAB-AAZG MED Q5135 TYKERB LAPATINIB PA

TYMLOS ABALOPARATIDE PA

TYRUKO NATALIZUMAB-SZTN MED Q5134 TYSABRI NATALIZUMAB MED J2323 TYVASO TREPROSTINOL PA

TZIELD TEPLIZUMAB-MZWV MED J9381 UBRELVY UBROGEPANT PA

UDENYCA/UDENYCA ONBODY PEGFILGRASTIM-CBQV MED Q5111 ULTOMIRIS RAVUILIZUMAB MED J1303 UNLOXCYT COSIBELIMAB-IPDL MED J9275 UPLIZNA INEBILIZUMAB MED J1823 UPTRAVI SELEXIPAG PA

USTEKINUMAB IV vial (Healthcare Administered) USTEKINUMAB MED J3358 USTEKINUMAB-AAUZ IV vial (Healthcare Administered) USTEKINUMAB-AAUZ MED Q9999 USTEKINUMAB-AEKN IV vial (Healthcare Administered) USTEKINUMAB-AEKN MED Q9998 USTEKINUMAB-STBA IV vial (Healthcare Administered) USTEKINUMAB-STBA MED Q5099 USTEKINUMAB-TTWE IV vial (Healthcare Administered) USTEKINUMAB-TTWE MED Q9997 USTEKINUMAB-TTWE prefilled syringe (Self-Administered) USTEKINUMAB-TTWE CE, PA

VABYSMO FARICIMAB-SVOA MED J2777 VANFLYTA QUIZARTINIB DIHYDROCHLORIDE TAB CE, PA

VANRAFIA ATRASENTAN HCL PA

VASCEPA ICOSAPENT ETHYL PA

VECTIBIX PANITUMUMAB MED J9303 VEGZELMA BEVACIZUMAB-ADCD MED Q5129

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) VELSIPITY ETRASIMOD ARGININE TAB CE, PA

VENCLEXTA VENETOCLAX PA

VENTAVIS ILOPROST PA

VEOPOZ POZELIMAB-BBFG MED J9376 VERZENIO ABEMACICLIB PA

VFEND VORICONAZOLE PA, CE (Brand only)

VICTOZA LIRAGLUTIDE CE, PA

VILTEPSO VILTOLARSEN MED J1427 VIMIZIM ELOSULFASE ALFA MED J1322 VIOKACE PANCRELIPASE (LIP-PROT-AMYL)
CE, PA

VISCO-3 SODIUM HYALURONATE MED J7321 VITRAKVI LAROTRECTINIB PA

VIVIMUSTA BENDAMUSTINE MED J9056 VIVJOA OTESECONAZOLE CE, PA

VIZIMPRO DACOITINIB PA

VONJO PACRITINIB PA

VONVENDI VON WILLEBRAND FACTOR (RECOMBINANT) PA

VORANIGO VORASIDENIB CE, PA

VOSEVI SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR PA

VOTRIENT PAZOPANIB PA

VPRIV VELAGLUCERASE ALFA MED J3385 VUMERITY DIROXIMEL FUMARATE PA

VYEPTI EPTINEZUMAB-JJMR MED J3032 VYJUVEK BEREMAGENE GEPERPAVEC-SVDT MED J3401 VYKAT XR DIAZOXIDE CHOLINE PA

VYLOY ZOLBETUXIMAB-CLZB MED J1326 VYNDAMAX TAFAMIDIS PA

VYNDAQEL TAFAMIDIS PA

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) VYONDYS-53 GOLODIRSEN MED J1429 VYVGART EFGARTIGIMOD ALFA-FCAB MED J9332 VYVGART HYTRULO EFGARTIGIMOD ALFA-HYALURONIDASE-QVFC MED J9334 WAINUA EPLONTERSEN SODIUM SUBCUTANEOUS SOLN AUTO-INJ
CE, PA

WAKIX PITOLISANT CE, PA

WAYRILZ RILZABRUTINIB TAB CE, PA

WELIREG BELZUTIFAN PA

WEZLANA USTEKINUMAB-AUUB SOLN PREFILLED SYRINGE CE, PA

WEZLANA IV USTEKINUMAB-AUUB MED Q5138 WILATE ANTIHEMOPHILIC FACTOR/VWF (HUMAN) PA

WINREVAIR SOTATERCEPT-CSRK FOR SUBCUTANEOUS SOLN KIT CE, PA

WYOST DENOSUMAB-BBDZ MED Q5136 XALKORI CRIZOTINIB PA, CE

XBRYK DENOSUMAB-DSSB MED Q5159 XELJANZ, XELJANZ XR TOFACITINIB PA

XELODA CAPECITABINE PA, CE (Brand only)

XEMBIFY IMMUNE GLOBULIN (HUMAN) SUBCUTANEOUS MED J1558 XENAZINE TETRABENAZINE PA, CE (Brand only)

XENPOZYME OLIPUDASE ALFA-RPCP MED J0218 XERMELO TELOTRISTAT PA

XGEVA DENOSUMAB MED J0897 XOLAIR prefilled syringe, auto-injector (Self-Administered) OMALIZUMAB PA

XOLAIR vial (Healthcare Administered)
OMALIZUMAB MED J2357 XOLREMDI MAVORIXAFOR PA

XOSPATA GILTERITINIB PA

XPOVIO SELINEXOR PA

XTANDI ENZALUTAMIDE PA

XTRENBO DENOSUMAB-QBDE MED J3590; C9399

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) XYNTHA ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) PA

XYNTHA SOLOFUSE ANTIHEMOPHIL FACT RCMB (BDD-RFVIII,MOR) PA

XYREM SODIUM OXYBATE CE, PA

XYWAV CALCIUM, MAG, POTASSIUM, & SOD OXYBATES PA

YARGESA MIGLUSTAT CE, PA

YARTEMLEA NARSOPLIMAB-WUUG MED J3590; C9399 YERVOY IPILIMUMAB MED J9228 YESAFILI AFLIBERCEPT-JBVF MED Q5155 YESCARTA AXICABTAGENE CILOLEUCEL MED Q2041 YESINTEK IV vial (Healthcare Administered) USTEKINUMAB-KFCE MED Q5100 YESINTEK prefilled syringe (Self-Administered) USTEKINUMAB-KFCE CE, PA

YIMMUGO IMMUNE GLOBULIN
MED J1553 YONDELIS TRABECTEDIN MED J9352 YONSA ABIRATERONE PA

YORVIPATH PALOPEGTERIPARATIDE (TERIPARATIDE EQ) PA

YUFLYMA ADALIMUMAB-AATY
CE, PA

YUSIMRY ADALIMUMAB-AQVH
CE, PA

YUTREPIA TREPROSTINIL SODIUM INHAL CE, PA

ZALTRAP ZIV-AFLIBERCEPT MED J9400 ZAVESCA MIGLUSTAT PA, CE (Brand only)

ZAVZPRET ZAVEGEPANT
CE, PA

ZEJULA NIRAPARIB PA

ZELBORAF VEMURAFENIB PA

ZELSUVMI BERDAZIMER SODIUM GEL 10.3% PA

ZEPATIER ELBASVIR-GRAZOPREVIR CE, PA

ZEPBOUND TIRZEPATIDE (WEIGHT MNGMT) CE, PA

ZEPOSIA OZANIMOD PA

ZEPOSIA OZANIMOD PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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BRAND DRUG NAME GENERIC DRUG NAME QHP 2025 AND 2026 PROCEDURE CODE (MED ONLY) ZEPZELCA LURBINECTEDIN MED J9223 ZEVASKYN PRADEMAGENE ZAMKIKERACEL MED J3389 ZIEXTENZO PEGFILGRASTIM-BMEZ MED Q5120 ZIIHERA ZANIDATAMAB-HRII MED J9276 ZILRETTA TRIAMCINOLONE ACETONIDE MED J3304 ZIRABEV BEVACIZUMAB-BVZR
MED Q5118 ZITUVIO SITAGLIPTIN TAB CE, PA

ZITUVIMET
SITAGLIPTIN FREE BASE-METFORMIN HCL CE, PA

ZITUVIMET XR SITAGLIPTIN FREE BASE-METFORMIN HCL CE, PA

ZOKINVY LONAFARNIB PA

ZOLGENSMA ONASEMNOGENE MED J3399 ZOLINZA VORINOSTAT PA

ZOMACTON SOMATROPIN CE, PA

ZORBTIVE SOMATROPIN CE, PA

ZUSDURI MITOMYCIN MED J9282 ZYDELIG IDELALISIB PA

ZYKADIA CERITINIB PA

ZYMFENTRA INFLIXIMAB-DYYB CE, PA

ZYNLONTA LONCASTUXIMA TESIRINE-LPYL MED J9359 ZYNTEGLO BETIBEGLOGENE AUTOTEMCEL MED J3393 ZYNYZ RETIFANLIMAB-DLWR IV MED J9345 ZYTIGA ABIRATERONE PA

CATEGORY BRAND DRUG NAME GENERIC DRUG NAME QHP 2024 QHP 2025 WEIGHT LOSS ADIPEX-P PHENTERMINE BENEFIT EXCLUSION CE, PA

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CATEGORY BRAND DRUG NAME GENERIC DRUG NAME QHP 2024 QHP 2025

Not all benefit plans cover Weight Loss medications. Please contact a Member Services representative for specific coverage information. BENZPHETAMINE BENZPHETAMINE BENEFIT EXCLUSION CE, PA CONTRAVE NALTREXONE/BUPROPION BENEFIT EXCLUSION CE, PA DIETHYLPROPION DIETHYLPROPION BENEFIT EXCLUSION CE, PA IMCIVREE SETMELANOTIDE BENEFIT EXCLUSION PA LIRAGLUTIDE LIRAGLUTIDE BENEFIT EXCLUSION PA LOMAIRA PHENTERMINE BENEFIT EXCLUSION PA QSYMIA PHENTERMINE/TOPIRAMATE BENEFIT EXCLUSION PA ORLISTAT ORLISTAT BENEFIT EXCLUSION PA PHENDIMETRAZINE PHENDIMETRAZINE BENEFIT EXCLUSION CE, PA XENICAL ORLISTAT BENEFIT EXCLUSION PA PHENTERMINE
PHENTERMINE BENEFIT EXCLUSION PA PHENTERMINE/TOPIRAMATE ER
PHENTERMINE HCL-TOPIRAMATE ER BENEFIT EXCLUSION CE, PA

CATEGORY BRAND DRUG NAME GENERIC DRUG NAME QHP 2024 QHP 2025 WEIGHT MANAGEMENT

Not all benefit plans cover Weight Management medications. Please contact a Member Services representative for specific coverage information. SAXENDA LIRAGLUTIDE BENEFIT EXCLUSION PA WEGOVY SEMAGLUTIDE
BENEFIT EXCLUSION PA WEGOVY HD SEMAGLUTIDE
BENEFIT EXCLUSION PA ZEPBOUND TIRZEPATIDE
BENEFIT EXCLUSION CE, PA ZEPBOUND KWIKPEN TIRZEPATIDE
BENEFIT EXCLUSION CE, PA

Blue Cross Blue Shield of North Dakota Restricted Use List – Prior Approval

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Drugs with Benefit Quantity Limits: The following list represents the drugs subject to a limited dispensing amount. SEXUAL DYSFUNCTION**, ORAL Daily and as-needed use prescriptions are not allowed concomitantly BRAND NAME GENERIC NAME FORMULARY STATUS Quantity Limit CIALIS 10 mg, 20 mg TADALAFIL NF A Combined Total of 18 tablets per 90 Days

A member can receive up to a combined total of 18 tablets per 90 days. The claims system will not allow any quantity >18 in any 90- day claims period.

LEVITRA VARDENAFIL NF STAXYN VARDENAFIL NF STENDRA AVANAFIL NF VIAGRA SILDENAFIL NF CIALIS Once-Daily Use 2.5 mg, 5 mg TADALAFIL NF 1 tab/day ADDYI FLIBANSERIN NF 1 tab/day VYLEESI (Injectable) BREMELANOTID NF 6 doses/30 days Medications used to treat sexual dysfunction are a benefit exclusion under Qualified Health Plans. Cialis Once Daily 5mg may be eligible for a Coverage Exception under Qualified Health Plans to treat benign prostatic hypertrophy (BPH).