NetResults Restricted Use List - Opioids Form

Blue Cross Blue Shield of North Dakota - NetResults 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 Net Results plans, 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/2019/FullyQualified/Other/ALL/BCBSND/COMMER CIAL/NDNETRF/ChoiceCEFEHDFax.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 NR NetResults Health Plan Net Results

The following List of Drugs represents the drugs requiring Prior Approval (PA) • 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. Dispensing limits are currently in place for all opioid ER products

BRAND (generic) DRUG NAME

BELBUCA PA buprenorphine patch PA BUTRANS PA CONZIP PA fentanyl transdermal patch PA HYDROCODONE CAP ER PA hydrocodone tab ER PA hydromorphone tab ER PA HYSINGLA ER PA MORPHINE SULFATE CAP ER PA morphine sulfate tab ER (generic for MS CONTIN) PA MS CONTIN PA NUCYNTA ER CE, PA OXYCODONE ER CE, PA OXYCONTIN PA OXYMORPHONE ER PA TAPENTADOL CE, PA TRAMADOL CAP ER PA TRAMADOL TAB ER PA XTAMPZA ER PA

Blue Cross Blue Shield of North Dakota - NetResults 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

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

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