Blue Cross Blue Shield of North Dakota Drug List Updates April 2020

Brand/ Generic TRADE NAME (generic name) or generic name Product Effective Date Description of Change colchicine tab 0.6 mg Generic 12/1/19 Addition, generic for COLCRYS COLCRYS (colchicine tab 0.6 mg) Brand 4/1/20 Removal, generics available deferasirox tab 360 mg Generic 11/24/19 Addition, generic for JADENU deferasirox tab 90 mg Generic 11/24/19 Addition, generic for JADENU DELZICOL (mesalamine cap dr 400 mg) Brand 4/1/20 Removal, generics available desoximetasone cream 0.05% Generic 4/1/20 Removal desoximetasone gel 0.05% Generic 4/1/20 Removal DEXCOM G5 MOBILE RECEIVERKIT (*continuous blood glucose system Brand 1/1/20 Addition receiver***) DEXCOM G5 MOBILE TRANSMITTER KIT (*continuous blood glucose Brand 1/1/20 Addition system transmitter***) DEXCOM G5 MOBILE/G4 PLATINUM SENSOR KIT (*continuous blood Brand 1/1/20 Addition glucose system sensor***) DEXCOM G5 RECEIVER KIT (*continuous blood glucose system receiver***) Brand 1/1/20 Addition DEXCOM G6 RECEIVER (*continuous blood glucose system receiver***) Brand 1/1/20 Addition DEXCOM G6 SENSOR (*continuous blood glucose system sensor***) Brand 1/1/20 Addition DEXCOM G6 TRANSMITTER (*continuous blood glucose system Brand 1/1/20 Addition transmitter***) DIFLORASONE DIACETATE (diflorasone diacetate cream 0.05%) Brand 4/1/20 Removal diflorasone diacetate oint 0.05% Generic 4/1/20 Removal DIGOXIN (digoxin oral soln 0.05 mg/ml) Brand 4/1/20 Removal, generics available DIVIGEL (estradiol td gel 1.25 mg/1.25gm (0.1%)) Brand 12/29/19 Addition EMEND (fosaprepitant dimeglumine for iv infusion 150 mg (base eq)) Brand 4/1/20 Removal, generics available everolimus tab 2.5 mg Generic 12/15/19 Addition, generic for AFINITOR everolimus tab 5 mg Generic 12/15/19 Addition, generic for AFINITOR everolimus tab 7.5 mg Generic 12/15/19 Addition, generic for AFINITOR FIRAZYR (icatibant acetate inj 30 mg/3ml (base equivalent)) Brand 4/1/20 Removal, generics available fluoxetine hcl tab 10 mg Generic 4/1/20 Removal fluoxetine hcl tab 20 mg Generic 4/1/20 Removal FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING SYSTEM Brand 1/1/20 Addition (*continuous blood glucose system receiver***) FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING SYSTEM Brand 1/1/20 Addition (*continuous blood glucose system sensor***) FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM Brand 1/1/20 Addition (*continuous blood glucose system receiver***) FREESTYLE LIBRE/SENSOR/FLASH MONITORING SYSTEM Brand 1/1/20 Addition (*continuous blood glucose system sensor***)

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April 2020 | Blue Cross Blue Shield of North Dakota Drug List Updates Brand/ Generic TRADE NAME (generic name) or generic name Product Effective Date Description of Change GVOKE PFS (glucagon subcutaneous soln pref syringe 0.5 mg/0.1ml) Brand 4/1/20 Addition GVOKE PFS (glucagon subcutaneous soln pref syringe 1 mg/0.2ml) Brand 4/1/20 Addition INSULIN ASPART (insulin aspart inj 100 unit/ml) Brand 12/17/19 Addition INSULIN ASPART FLEXPEN (insulin aspart soln pen-injector 100 unit/ml) Brand 12/17/19 Addition INSULIN ASPART PENFILL (insulin aspart soln cartridge 100 unit/ml) Brand 12/17/19 Addition INSULIN ASPART PROTAMINE/INSULIN ASPART (insulin aspart prot & Brand 12/17/19 Addition aspart (human) inj 100 unit/ml (70-30)) INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN (insulin aspart Brand 12/17/19 Addition prot & aspart sus pen-inj 100 unit/ml (70-30)) JADENU (deferasirox tab 360 mg) Brand 4/1/20 Removal, generics available JADENU (deferasirox tab 90 mg) Brand 4/1/20 Removal, generics available mesalamine cap er 24hr 0.375 gm Generic 12/1/19 Addition, generic for APRISO naproxen susp 125 mg/5ml Generic 4/1/20 Removal NOVOLIN N FLEXPEN (insulin nph (human) (isophane) susp pen-injector Brand 12/22/19 Addition 100 unit/ml) NOVOLIN R FLEXPEN (insulin regular (human) soln pen-injector 100 unit/ml) Brand 12/22/19 Addition NPLATE (romiplostim for inj 125 mcg) Brand 11/24/19 Addition NUBEQA (darolutamide tab 300 mg) Brand 4/1/20 Addition OCTREOTIDE ACETATE (octreotide acetate inj 1000 mcg/ml (1 mg/ml)) Brand 4/1/20 Removal, generics available OCTREOTIDE ACETATE (octreotide acetate inj 200 mcg/ml (0.2 mg/ml)) Brand 4/1/20 Removal, generics available penicillamine tab 250 mg Generic 1/5/20 Addition, generic for DEPEN TITRATABS pentamidine isethionate for nebulization soln 300 mg Generic 12/8/19 Addition, generic for NEBUPENT ROZLYTREK (entrectinib cap 100 mg) Brand 4/1/20 Addition ROZLYTREK (entrectinib cap 200 mg) Brand 4/1/20 Addition RUBRACA (rucaparib camsylate tab 200 mg (base equivalent)) Brand 4/1/20 Addition RUBRACA (rucaparib camsylate tab 250 mg (base equivalent)) Brand 4/1/20 Addition RUBRACA (rucaparib camsylate tab 300 mg (base equivalent)) Brand 4/1/20 Addition RYBELSUS (semaglutide tab 14 mg) Brand 4/1/20 Addition RYBELSUS (semaglutide tab 3 mg) Brand 4/1/20 Addition RYBELSUS (semaglutide tab 7 mg) Brand 4/1/20 Addition TEMIXYS (lamivudine-tenofovir disoproxil fumarate tab 300-300 mg) Brand 4/1/20 Addition travoprost ophth soln 0.004% (benzalkonium free) (bak free) Generic 12/22/19 Addition, generic for TRAVATAN Z TRIKAFTA (elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor 150 mg tbpk) Brand 2/1/20 Addition TRISENOX (arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)) Brand 4/1/20 Removal, generics available

April 2020 | Blue Cross Blue Shield of North Dakota Drug List Updates Utilization Management Implementations Prior Authorizations and Step Therapy Programs

Medications Utilization Management Ayvakit (ayvapritinib) PA and QL Caplyta (lumateperone) ST and QL Dexcom G5 and G6 and associated supplies PA and QL Freestyle Libre and associated supplies PA and QL Ozobax (baclofen) PA and QL Procysbi (cysteamine bitartrate) PA Secuado (asenapine) ST and QL Tazverik (tazemetostat) PA and QL Ubrelvy (ubrogepant) PA and QL Wakix (pitolisant) PA and QL

Dispensing Limits

Medication Name Dispensing Limit Ayvakit (ayvapritinib) 1 tablet per day Caplyta (lumateperone) 1 capsule per day Coseni (amlodipine/celecoxib) 1 tablet per day Dexcom G5 and G6 receiver 1 receiver every 365 days Dexcom G5 transmitter 1 transmitter every 84 days Dexcom G5 sensor 1 sensor every 7 days Dexcom G6 sensor 1 sensor every 10 days Freestyle Libre Reader 1 reader every 365 days Freestyle Libre Sensor 1 sensor every 14 days Jatenzo (testosterone) 158 mg, 237 mg 2 capsules per day Jatenzo (testosterone) 198 mg 4 capsules per day Nayzilam (midazolam) 10 bottles per 30 days Ozobax (baclofen) 2400 mL per 30 days Secuado (asenapine) 1 patch per day Tazverik (tazemetostat) 8 tablets per day Ubrelvy (ubrogepant) 16 tablets per 30 days Valtoco (diazepam) 5 boxes per 30 days Wakix (pitolisant) 2 tablets per day

Note: Coverage is subject to each member’s specific benefits. Group specific policies will superesede these policies when applicable. Please refer to the member’s benefit plans.

For complete details, medical policies may be viewed on the Blue Cross website at https://www.bcbsnd.com/quantitylimits