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Blue Cross Blue Shield of North Dakota Specialty Drug List

Specialty Drug – or drugs that are generally high cost and may have other considerations such as special drug administration, limited availability, unique delivery and dispensing or unique and/or required patient support or monitoring.

Use of some products may be approved only after certain criteria are met. Refer to Restricted-Use Drug lists for other applicable criteria.

DRUG NAME(S) GENERIC NAME ABIRATERONE ACETATE ABIRATERONE ACETATE TAB 250 MG, ABIRATERONE ACETATE TAB 500 MG ACTEMRA TOCILIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 162 MG/0.9ML ACTEMRA ACTPEN TOCILIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 162 MG/0.9ML ACTHAR CORTICOTROPIN INJ GEL 80 UNIT/ML ACTIMMUNE GAMMA-1B INJ 100 MCG/0.5ML (2000000 UNIT/0.5ML) ADCIRCA TADALAFIL TAB 20 MG (PAH) RIOCIGUAT TAB 0.5 MG, RIOCIGUAT TAB 1 MG, RIOCIGUAT TAB 1.5 MG, RIOCIGUAT TAB 2 MG, RIOCIGUAT ADEMPAS TAB 2.5 MG AFINITOR EVEROLIMUS TAB 10 MG, EVEROLIMUS TAB 2.5 MG, EVEROLIMUS TAB 5 MG, EVEROLIMUS TAB 7.5 MG EVEROLIMUS TAB FOR ORAL SUSP 2 MG, EVEROLIMUS TAB FOR ORAL SUSP 3 MG, EVEROLIMUS TAB FOR AFINITOR DISPERZ ORAL SUSP 5 MG ALECENSA ALECTINIB HCL CAP 150 MG (BASE EQUIVALENT) ALFERON N -N3 INJ 5000000 UNIT/ML ALKERAN MELPHALAN TAB 2 MG HYDROCORTISONE CAP SPRINKLE 0.5 MG, HYDROCORTISONE CAP SPRINKLE 1 MG, HYDROCORTISONE CAP ALKINDI SPRINKLE SPRINKLE 2 MG, HYDROCORTISONE CAP SPRINKLE 5 MG BRIGATINIB TAB 180 MG, BRIGATINIB TAB 30 MG, BRIGATINIB TAB 90 MG, BRIGATINIB TAB INITIATION ALUNBRIG THERAPY PACK 90 MG & 180 MG ALYQ TADALAFIL TAB 20 MG (PAH) AMBRISENTAN AMBRISENTAN TAB 10 MG, AMBRISENTAN TAB 5 MG AMPYRA DALFAMPRIDINE TAB ER 12HR 10 MG APOKYN APOMORPHINE HCL SOLN CARTRIDGE 30 MG/3ML SOLN INJ 100 MCG/ML, DARBEPOETIN ALFA SOLN INJ 200 MCG/ML, DARBEPOETIN ALFA SOLN INJ 25 MCG/ML, DARBEPOETIN ALFA SOLN INJ 300 MCG/ML, DARBEPOETIN ALFA SOLN INJ 40 MCG/ML, DARBEPOETIN ALFA SOLN INJ 60 MCG/ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 10 MCG/0.4ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 100 MCG/0.5ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE ARANESP ALBUMIN FREE 150 MCG/0.3ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 200 MCG/0.4ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 25 MCG/0.42ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 300 MCG/0.6ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 40 MCG/0.4ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 500 MCG/ML, DARBEPOETIN ALFA SOLN PREFILLED SYRINGE 60 MCG/0.3ML ARCALYST RILONACEPT FOR INJ 220 MG ARIKAYCE AMIKACIN SULFATE LIPOSOME INHAL SUSP 590 MG/8.4ML (BASE EQ) AUBAGIO TERIFLUNOMIDE TAB 14 MG, TERIFLUNOMIDE TAB 7 MG AUSTEDO DEUTETRABENAZINE TAB 12 MG, DEUTETRABENAZINE TAB 6 MG, DEUTETRABENAZINE TAB 9 MG AVONEX INTERFERON BETA-1A IM PREFILLED SYRINGE KIT 30 MCG/0.5ML AVONEX PEN INTERFERON BETA-1A IM AUTO-INJECTOR KIT 30 MCG/0.5ML AYVAKIT AVAPRITINIB TAB 100 MG, AVAPRITINIB TAB 200 MG, AVAPRITINIB TAB 300 MG BAFIERTAM MONOMETHYL FUMARATE CAPSULE DELAYED RELEASE 95 MG BALVERSA ERDAFITINIB TAB 3 MG, ERDAFITINIB TAB 4 MG, ERDAFITINIB TAB 5 MG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML, BELIMUMAB SUBCUTANEOUS BENLYSTA SOLUTION PREFILLED SYRINGE 200 MG/ML BERINERT C1 ESTERASE INHIBITOR (HUMAN) FOR IV INJ KIT 500 UNIT BETASERON INTERFERON BETA-1B FOR INJ KIT 0.3 MG BETHKIS TOBRAMYCIN NEBU SOLN 300 MG/4ML BEXAROTENE BEXAROTENE CAP 75 MG BOSENTAN BOSENTAN TAB 125 MG, BOSENTAN TAB 62.5 MG BOSULIF BOSUTINIB TAB 100 MG, BOSUTINIB TAB 400 MG, BOSUTINIB TAB 500 MG BRAFTOVI ENCORAFENIB CAP 50 MG, ENCORAFENIB CAP 75 MG BRAVELLE UROFOLLITROPIN PURIFIED FOR INJ 75 UNIT BRONCHITOL MANNITOL INHAL CAP 40 MG

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DRUG NAME(S) GENERIC NAME BRONCHITOL TOLERANCE MANNITOL INHAL CAP 40 MG TEST BRUKINSA ZANUBRUTINIB CAP 80 MG BUPHENYL ORAL POWDER 3 GM/TEASPOONFUL, SODIUM PHENYLBUTYRATE TAB 500 MG BYNFEZIA PEN OCTREOTIDE ACETATE SOLN PEN-INJECTOR 2500 MCG/ML (2.8 ML) CABLIVI CAPLACIZUMAB-YHDP FOR INJ KIT 11 MG CABOZANTINIB S-MALATE TAB 20 MG (BASE EQUIVALENT), CABOZANTINIB S-MALATE TAB 40 MG (BASE CABOMETYX EQUIVALENT), CABOZANTINIB S-MALATE TAB 60 MG (BASE EQUIVALENT) CALQUENCE ACALABRUTINIB CAP 100 MG CAPECITABINE CAPECITABINE TAB 150 MG, CAPECITABINE TAB 500 MG CAPRELSA VANDETANIB TAB 100 MG, VANDETANIB TAB 300 MG CARBAGLU TAB 200 MG CAYSTON AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT) CERDELGA TARTRATE CAP 84 MG (BASE EQUIVALENT) CETROTIDE CETRORELIX ACETATE FOR INJ KIT 0.25 MG CHENODAL CHENODIOL TAB 250 MG CHOLBAM CHOLIC ACID CAP 250 MG, CHOLIC ACID CAP 50 MG CHORIONIC CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT GONADOTROPIN CIMZIA CERTOLIZUMAB PEGOL FOR INJ KIT 2 X 200 MG, CERTOLIZUMAB PEGOL INJ KIT 2 X 200 MG/ML CIMZIA STARTER KIT CERTOLIZUMAB PEGOL INJ KIT 6 X 200 MG/ML CINACALCET CINACALCET HCL TAB 30 MG (BASE EQUIV), CINACALCET HCL TAB 60 MG (BASE EQUIV), CINACALCET HCL TAB HYDROCHLORIDE 90 MG (BASE EQUIV) CLOVIQUE TRIENTINE HCL CAP 250 MG CABOZANTINIB S-MAL CAP 1 X 80 MG & 1 X 20 MG (100 DOSE) KIT, CABOZANTINIB S-MAL CAP 1 X 80 MG & 3 COMETRIQ X 20 MG (140 DOSE) KIT, CABOZANTINIB S-MALATE CAP 3 X 20 MG (60 MG DOSE) KIT SOLN PREFILLED SYRINGE 20 MG/ML, GLATIRAMER ACETATE SOLN PREFILLED COPAXONE SYRINGE 40 MG/ML COPIKTRA DUVELISIB CAP 15 MG, DUVELISIB CAP 25 MG SECUKINUMAB SUBCUTANEOUS PREF SYR 150 MG/ML (300 MG DOSE), SECUKINUMAB SUBCUTANEOUS COSENTYX SOLN PREFILLED SYRINGE 150 MG/ML, SECUKINUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML COSENTYX SENSOREADY SECUKINUMAB SUBCUTANEOUS AUTO-INJ 150 MG/ML (300 MG DOSE), SECUKINUMAB SUBCUTANEOUS PEN SOLN AUTO-INJECTOR 150 MG/ML COTELLIC COBIMETINIB FUMARATE TAB 20 MG (BASE EQUIVALENT) CRYSVITA BUROSUMAB-TWZA INJ 10 MG/ML, BUROSUMAB-TWZA INJ 20 MG/ML, BUROSUMAB-TWZA INJ 30 MG/ML CUPRIMINE PENICILLAMINE CAP 250 MG CYSTADROPS HCL OPHTH SOLN 0.37% (BASE EQUIVALENT) CYSTAGON CYSTEAMINE BITARTRATE CAP 150 MG, CYSTEAMINE BITARTRATE CAP 50 MG CYSTARAN CYSTEAMINE HCL OPHTH SOLN 0.44% (BASE EQUIVALENT) DACLATASVIR DIHYDROCHLORIDE TAB 30 MG (BASE EQUIVALENT), DACLATASVIR DIHYDROCHLORIDE TAB 60 DAKLINZA MG (BASE EQUIVALENT) DALFAMPRIDINE ER DALFAMPRIDINE TAB ER 12HR 10 MG GLASDEGIB MALEATE TAB 100 MG (BASE EQUIVALENT), GLASDEGIB MALEATE TAB 25 MG (BASE DAURISMO EQUIVALENT) DEFERASIROX GRANULES PACKET 180 MG, DEFERASIROX GRANULES PACKET 360 MG, DEFERASIROX GRANULES PACKET 90 MG, DEFERASIROX TAB 180 MG, DEFERASIROX TAB 360 MG, DEFERASIROX TAB 90 MG, DEFERASIROX DEFERASIROX TAB FOR ORAL SUSP 125 MG, DEFERASIROX TAB FOR ORAL SUSP 250 MG, DEFERASIROX TAB FOR ORAL SUSP 500 MG DEFERIPRONE DEFERIPRONE TAB 500 MG DEPEN TITRATABS PENICILLAMINE TAB 250 MG STIRIPENTOL CAP 250 MG, STIRIPENTOL CAP 500 MG, STIRIPENTOL PACKET 250 MG, STIRIPENTOL PACKET DIACOMIT 500 MG DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG, DIMETHYL FUMARATE CAPSULE DELAYED DIMETHYL FUMARATE RELEASE 240 MG

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DRUG NAME(S) GENERIC NAME DIMETHYL FUMARATE DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG STARTERPACK DOJOLVI ORAL LIQUID 100% DOPTELET AVATROMBOPAG MALEATE TAB 20 MG (BASE EQUIV) DROXIA HYDROXYUREA CAP 200 MG, HYDROXYUREA CAP 300 MG, HYDROXYUREA CAP 400 MG DROXIDOPA DROXIDOPA CAP 100 MG, DROXIDOPA CAP 200 MG, DROXIDOPA CAP 300 MG DUPILUMAB SUBCUTANEOUS SOLN PEN-INJECTOR 200 MG/1.14ML, DUPILUMAB SUBCUTANEOUS SOLN PEN- DUPIXENT INJECTOR 300 MG/2ML, DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 200 MG/1.14ML, DUPILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 300 MG/2ML EGRIFTA TESAMORELIN ACETATE FOR INJ 1 MG (BASE EQUIV) EGRIFTA SV TESAMORELIN ACETATE FOR INJ 2 MG (BASE EQUIV) LEUPROLIDE ACETATE (3 MONTH) FOR SUBCUTANEOUS INJ KIT 22.5MG, LEUPROLIDE ACETATE (4 MONTH) ELIGARD FOR SUBCUTANEOUS INJ KIT 30 MG, LEUPROLIDE ACETATE (6 MONTH) FOR SUBCUTANEOUS INJ KIT 45 MG, LEUPROLIDE ACETATE FOR SUBCUTANEOUS INJ KIT 7.5 MG DEFLAZACORT SUSP 22.75 MG/ML, DEFLAZACORT TAB 18 MG, DEFLAZACORT TAB 30 MG, DEFLAZACORT TAB EMFLAZA 36 MG, DEFLAZACORT TAB 6 MG EMPAVELI PEGCETACOPLAN SUBCUTANEOUS SOLN 1080 MG/20ML (54 MG/ML) FOR SUBCUTANEOUS INJ 25 MG, ETANERCEPT SUBCUTANEOUS INJ 25 MG/0.5ML, ETANERCEPT ENBREL SUBCUTANEOUS SOLN PREFILLED SYRINGE 25 MG/0.5ML, ETANERCEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/ML ENBREL MINI ETANERCEPT SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML ENBREL SURECLICK ETANERCEPT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ENDARI (SICKLE CELL) POWD PACK 5 GM ENSPRYNG SATRALIZUMAB-MWGE SUBCUTANEOUS SOLN PREF SYRINGE 120 MG/ML EPCLUSA SOFOSBUVIR-VELPATASVIR TAB 200-50 MG, SOFOSBUVIR-VELPATASVIR TAB 400-100 MG EPIDIOLEX CANNABIDIOL SOLN 100 MG/ML INJ 10000 UNIT/ML, EPOETIN ALFA INJ 2000 UNIT/ML, EPOETIN ALFA INJ 20000 UNIT/ML, EPOGEN EPOETIN ALFA INJ 3000 UNIT/ML, EPOETIN ALFA INJ 4000 UNIT/ML ERIVEDGE VISMODEGIB CAP 150 MG ERLEADA APALUTAMIDE TAB 60 MG ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT), ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT), ERLOTINIB HYDROCHLORIDE ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) ESBRIET PIRFENIDONE CAP 267 MG, PIRFENIDONE TAB 267 MG, PIRFENIDONE TAB 801 MG ETOPOSIDE ETOPOSIDE CAP 50 MG EVENITY ROMOSOZUMAB-AQQG INJ SOLN PREFILLED SYRINGE 105 MG/1.17ML EVEROLIMUS EVEROLIMUS TAB 2.5 MG, EVEROLIMUS TAB 5 MG, EVEROLIMUS TAB 7.5 MG EVRYSDI RISDIPLAM FOR SOLN 0.75 MG/ML DEFERASIROX TAB FOR ORAL SUSP 125 MG, DEFERASIROX TAB FOR ORAL SUSP 250 MG, DEFERASIROX TAB EXJADE FOR ORAL SUSP 500 MG EXSERVAN RILUZOLE ORAL FILM 50 MG EXTAVIA INTERFERON BETA-1B FOR INJ KIT 0.3 MG PANOBINOSTAT LACTATE CAP 10 MG (BASE EQUIVALENT), PANOBINOSTAT LACTATE CAP 15 MG (BASE FARYDAK EQUIVALENT), PANOBINOSTAT LACTATE CAP 20 MG (BASE EQUIVALENT) FASENRA BENRALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 30 MG/ML FASENRA PEN BENRALIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 30 MG/ML FENSOLVI LEUPROLIDE ACET (6 MONTH) FOR INJ PEDIATRIC KIT 45 MG FERRIPROX DEFERIPRONE ORAL SOLN 100 MG/ML, DEFERIPRONE TAB 1000 MG, DEFERIPRONE TAB 500 MG FERRIPROX TWICE-A-DAY DEFERIPRONE (TWICE DAILY) TAB 1000 MG FINTEPLA FENFLURAMINE HCL ORAL SOLN 2.2 MG/ML FIRAZYR ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) FIRDAPSE AMIFAMPRIDINE TAB 10 MG (BASE EQUIVALENT) FOLLITROPIN BETA INJ 300 UNIT/0.36ML, FOLLITROPIN BETA INJ 600 UNIT/0.72ML, FOLLITROPIN BETA INJ FOLLISTIM AQ 900 UNIT/1.08ML FORTEO TERIPARATIDE (RECOMBINANT) SOLN PEN-INJ 620 MCG/2.48ML FOTIVDA TIVOZANIB HCL CAP 1340 MCG (BASE EQUIVALENT), TIVOZANIB HCL CAP 890 MCG (BASE EQUIVALENT) FULPHILA -JMDB SOLN PREFILLED SYRINGE 6 MG/0.6ML

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DRUG NAME(S) GENERIC NAME FUZEON ENFUVIRTIDE FOR INJ 90 MG GALAFOLD MIGALASTAT HCL CAP 123 MG (BASE EQUIVALENT) GANIRELIX ACETATE GANIRELIX ACETATE SOLN PREFILLED SYRINGE 250 MCG/0.5ML GATTEX (RDNA) FOR INJ KIT 5 MG GAVRETO PRALSETINIB CAP 100 MG GENOTROPIN SOMATROPIN FOR INJ 12 MG (13.8 MG OVERFILL), SOMATROPIN FOR SUBCUTANEOUS INJ 5 MG SOMATROPIN FOR INJ 0.2 MG, SOMATROPIN FOR INJ 0.4 MG, SOMATROPIN FOR INJ 0.6 MG, SOMATROPIN GENOTROPIN MINIQUICK FOR INJ 0.8 MG, SOMATROPIN FOR INJ 1 MG, SOMATROPIN FOR INJ 1.2 MG, SOMATROPIN FOR INJ 1.4 MG, SOMATROPIN FOR INJ 1.6 MG, SOMATROPIN FOR INJ 1.8 MG, SOMATROPIN FOR INJ 2 MG GILENYA FINGOLIMOD HCL CAP 0.25 MG (BASE EQUIV), FINGOLIMOD HCL CAP 0.5 MG (BASE EQUIV) AFATINIB DIMALEATE TAB 20 MG (BASE EQUIVALENT), AFATINIB DIMALEATE TAB 30 MG (BASE EQUIVALENT), GILOTRIF AFATINIB DIMALEATE TAB 40 MG (BASE EQUIVALENT) GIVLAARI SODIUM SUBCUTANEOUS SOLN 189 MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML, GLATIRAMER ACETATE SOLN PREFILLED GLATIRAMER ACETATE SYRINGE 40 MG/ML GLATIRAMER ACETATE SOLN PREFILLED SYRINGE 20 MG/ML, GLATIRAMER ACETATE SOLN PREFILLED GLATOPA SYRINGE 40 MG/ML GLEEVEC IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT), IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) AMANTADINE HCL CAP ER 24HR 137 MG (BASE EQUIVALENT), AMANTADINE HCL CAP ER 24HR 68.5 MG (BASE GOCOVRI EQUIVALENT) GONAL-F FOLLITROPIN ALFA FOR INJ 1050 UNIT, FOLLITROPIN ALFA FOR INJ 450 UNIT GONAL-F RFF FOLLITROPIN ALFA FOR SUBCUTANEOUS INJ 75 UNIT FOLLITROPIN ALFA INJ 300 UNIT/0.5ML, FOLLITROPIN ALFA INJ 450 UNIT/0.75ML, FOLLITROPIN ALFA INJ 900 GONAL-F RFF REDIJECT UNIT/1.5ML TBO- SOLN PREFILLED SYRINGE 300 MCG/0.5ML, TBO-FILGRASTIM SOLN PREFILLED SYRINGE 480 GRANIX MCG/0.8ML, TBO-FILGRASTIM SUBCUTANEOUS INJ 300 MCG/ML, TBO-FILGRASTIM SUBCUTANEOUS INJ 480 MCG/1.6ML (300 MCG/ML) C1 ESTERASE INHIBITOR (HUMAN) FOR SUBCUTANEOUS INJ 2000 UNIT, C1 ESTERASE INHIBITOR (HUMAN) HAEGARDA FOR SUBCUTANEOUS INJ 3000 UNIT LEDIPASVIR-SOFOSBUVIR PELLET PACK 33.75-150 MG, LEDIPASVIR-SOFOSBUVIR PELLET PACK 45-200 MG, HARVONI LEDIPASVIR-SOFOSBUVIR TAB 45-200 MG, LEDIPASVIR-SOFOSBUVIR TAB 90-400 MG EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 105 MG/0.7ML (150 MG/ML), EMICIZUMAB-KXWH HEMLIBRA SUBCUTANEOUS SOLN 150 MG/ML, EMICIZUMAB-KXWH SUBCUTANEOUS SOLN 30 MG/ML, EMICIZUMAB- KXWH SUBCUTANEOUS SOLN 60 MG/0.4ML (150 MG/ML) HETLIOZ TASIMELTEON CAPSULE 20 MG HETLIOZ LQ TASIMELTEON ORAL SUSP 4 MG/ML HUMATROPE SOMATROPIN FOR INJ 12 MG (36 UNIT), SOMATROPIN FOR INJ 24 MG, SOMATROPIN FOR INJ 6 MG (18 UNIT) HUMATROPE COMBO PACK SOMATROPIN FOR INJ 5 MG ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.1ML, ADALIMUMAB PREFILLED SYRINGE KIT 10 MG/0.2ML, HUMIRA ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.2ML, ADALIMUMAB PREFILLED SYRINGE KIT 20 MG/0.4ML, ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.4ML, ADALIMUMAB PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEDIATRIC CROHNS ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML, ADALIMUMAB PREFILLED SYRINGE KIT 80 MG/0.8ML & DISEASE STARTER PACK 40 MG/0.4ML ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.4ML, ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML, HUMIRA PEN ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML HUMIRA PEN-CD/UC/HS ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML, ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML STARTER HUMIRA PEN-PEDIATRIC UC ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML STARTER PACK HUMIRA PEN-PS/UV ADALIMUMAB PEN-INJECTOR KIT 40 MG/0.8ML, ADALIMUMAB PEN-INJECTOR KIT 80 MG/0.8ML & 40 STARTER MG/0.4ML HYCAMTIN TOPOTECAN HCL CAP 0.25 MG (BASE EQUIV), TOPOTECAN HCL CAP 1 MG (BASE EQUIV) HYDROXYPROGESTERONE HYDROXYPROGESTERONE CAPROATE IM IN OIL 1.25 GM/5ML, HYDROXYPROGESTERONE CAPROATE IM IN OIL CAPROATE 250 MG/ML PALBOCICLIB CAP 100 MG, PALBOCICLIB CAP 125 MG, PALBOCICLIB CAP 75 MG, PALBOCICLIB TAB 100 MG, IBRANCE PALBOCICLIB TAB 125 MG, PALBOCICLIB TAB 75 MG ICATIBANT ACETATE ICATIBANT ACETATE INJ 30 MG/3ML (BASE EQUIVALENT) Blue Cross Blue Shield of North Dakota Updated 9/1/2021 Page 4 of 12 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change Blue Cross Blue Shield of North Dakota Specialty Drug List

DRUG NAME(S) GENERIC NAME PONATINIB HCL TAB 10 MG (BASE EQUIV), PONATINIB HCL TAB 15 MG (BASE EQUIV), PONATINIB HCL TAB 30 ICLUSIG MG (BASE EQUIV), PONATINIB HCL TAB 45 MG (BASE EQUIV) ENASIDENIB MESYLATE TAB 100 MG (BASE EQUIVALENT), ENASIDENIB MESYLATE TAB 50 MG (BASE IDHIFA EQUIVALENT) ILARIS CANAKINUMAB SUBCUTANEOUS INJ 150 MG/ML IMATINIB MESYLATE IMATINIB MESYLATE TAB 100 MG (BASE EQUIVALENT), IMATINIB MESYLATE TAB 400 MG (BASE EQUIVALENT) IBRUTINIB CAP 140 MG, IBRUTINIB CAP 70 MG, IBRUTINIB TAB 140 MG, IBRUTINIB TAB 280 MG, IBRUTINIB IMBRUVICA TAB 420 MG, IBRUTINIB TAB 560 MG IMCIVREE SETMELANOTIDE ACETATE SUBCUTANEOUS SOLN 10 MG/ML INBRIJA LEVODOPA INHAL POWDER CAP 42 MG INCRELEX MECASERMIN INJ 40 MG/4ML (10 MG/ML) VALBENAZINE TOSYLATE CAP 40 MG (BASE EQUIV), VALBENAZINE TOSYLATE CAP 60 MG (BASE EQUIV), INGREZZA VALBENAZINE TOSYLATE CAP 80 MG (BASE EQUIV), VALBENAZINE TOSYLATE CAP THERAPY PACK 40 MG (7) & 80 MG (21) INLYTA AXITINIB TAB 1 MG, AXITINIB TAB 5 MG INQOVI DECITABINE-CEDAZURIDINE TAB 35-100 MG INREBIC FEDRATINIB HCL CAP 100 MG INTERFERON ALFA-2B FOR INJ 10000000 UNIT, INTERFERON ALFA-2B FOR INJ 18000000 UNIT, INTERFERON INTRON A ALFA-2B FOR INJ 50000000 UNIT, INTERFERON ALFA-2B INJ 10000000 UNIT/ML, INTERFERON ALFA-2B INJ 6000000 UNIT/ML IRESSA GEFITINIB TAB 250 MG OSILODROSTAT PHOSPHATE TAB 1 MG, OSILODROSTAT PHOSPHATE TAB 10 MG, OSILODROSTAT PHOSPHATE ISTURISA TAB 5 MG JADENU DEFERASIROX TAB 180 MG, DEFERASIROX TAB 360 MG, DEFERASIROX TAB 90 MG DEFERASIROX GRANULES PACKET 180 MG, DEFERASIROX GRANULES PACKET 360 MG, DEFERASIROX JADENU SPRINKLE GRANULES PACKET 90 MG PHOSPHATE TAB 10 MG (BASE EQUIVALENT), RUXOLITINIB PHOSPHATE TAB 15 MG (BASE JAKAFI EQUIVALENT), RUXOLITINIB PHOSPHATE TAB 20 MG (BASE EQUIVALENT), RUXOLITINIB PHOSPHATE TAB 25 MG (BASE EQUIVALENT), RUXOLITINIB PHOSPHATE TAB 5 MG (BASE EQUIVALENT) LOMITAPIDE MESYLATE CAP 10 MG (BASE EQUIV), LOMITAPIDE MESYLATE CAP 20 MG (BASE EQUIV), JUXTAPID LOMITAPIDE MESYLATE CAP 30 MG (BASE EQUIV), LOMITAPIDE MESYLATE CAP 40 MG (BASE EQUIV), LOMITAPIDE MESYLATE CAP 5 MG (BASE EQUIV), LOMITAPIDE MESYLATE CAP 60 MG (BASE EQUIV) TOLVAPTAN TAB 15 MG, TOLVAPTAN TAB 30 MG, TOLVAPTAN TAB THERAPY PACK 15 MG, TOLVAPTAN TAB JYNARQUE THERAPY PACK 30 & 15 MG, TOLVAPTAN TAB THERAPY PACK 45 & 15 MG, TOLVAPTAN TAB THERAPY PACK 60 & 30 MG, TOLVAPTAN TAB THERAPY PACK 90 & 30 MG KALBITOR ECALLANTIDE INJ 10 MG/ML KALYDECO IVACAFTOR PACKET 25 MG, IVACAFTOR PACKET 50 MG, IVACAFTOR PACKET 75 MG, IVACAFTOR TAB 150 MG KESIMPTA OFATUMUMAB SOLN AUTO-INJECTOR 20 MG/0.4ML SARILUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 150 MG/1.14ML, SARILUMAB SUBCUTANEOUS SOLN KEVZARA PREFILLED SYRINGE 200 MG/1.14ML, SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, SARILUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/1.14ML KINERET ANAKINRA SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/0.67ML RIBOCICLIB SUCCINATE TAB PACK 200 MG DAILY DOSE, RIBOCICLIB SUCCINATE TAB PACK 400 MG DAILY DOSE KISQALI (200 MG TAB), RIBOCICLIB SUCCINATE TAB PACK 600 MG DAILY DOSE (200 MG TAB) KISQALI FEMARA 200 DOSE RIBOCICLIB 200 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK KISQALI FEMARA 400 DOSE RIBOCICLIB 400 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK KISQALI FEMARA 600 DOSE RIBOCICLIB 600 MG DOSE (200 MG TAB) & LETROZOLE 2.5 MG TBPK KITABIS PAK TOBRAMYCIN NEBU SOLN 300 MG/5ML KORLYM MIFEPRISTONE TAB 300 MG KOSELUGO SELUMETINIB SULFATE CAP 10 MG, SELUMETINIB SULFATE CAP 25 MG SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG, SAPROPTERIN DIHYDROCHLORIDE POWDER KUVAN PACKET 500 MG, SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG LAPATINIB DITOSYLATE LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) LEDIPASVIR/SOFOSBUVIR LEDIPASVIR-SOFOSBUVIR TAB 90-400 MG LENVIMA 10 MG DAILY LENVATINIB CAP THERAPY PACK 10 MG (10 MG DAILY DOSE) DOSE LENVIMA 12MG DAILY DOSE LENVATINIB CAP THERAPY PACK 3 X 4 MG (12 MG DAILY DOSE) Blue Cross Blue Shield of North Dakota Updated 9/1/2021 Page 5 of 12 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change Blue Cross Blue Shield of North Dakota Specialty Drug List

DRUG NAME(S) GENERIC NAME LENVIMA 14 MG DAILY LENVATINIB CAP THERAPY PACK 10 & 4 MG (14 MG DAILY DOSE) DOSE LENVIMA 18 MG DAILY LENVATINIB CAP THER PACK 10 MG & 2 X 4 MG (18 MG DAILY DOSE) DOSE LENVIMA 20 MG DAILY LENVATINIB CAP THERAPY PACK 2 X 10 MG (20 MG DAILY DOSE) DOSE LENVIMA 24 MG DAILY LENVATINIB CAP THER PACK 2 X 10 MG & 4 MG (24 MG DAILY DOSE) DOSE LENVIMA 4 MG DAILY DOSE LENVATINIB CAP THERAPY PACK 4 MG (4 MG DAILY DOSE) LENVIMA 8 MG DAILY DOSE LENVATINIB CAP THERAPY PACK 2 X 4 MG (8 MG DAILY DOSE) LETAIRIS AMBRISENTAN TAB 10 MG, AMBRISENTAN TAB 5 MG LEUKINE LYOPHILIZED FOR INJ 250 MCG LEUPROLIDE ACETATE LEUPROLIDE ACETATE INJ KIT 5 MG/ML LONSURF TRIFLURIDINE-TIPIRACIL TAB 15-6.14 MG, TRIFLURIDINE-TIPIRACIL TAB 20-8.19 MG LORBRENA LORLATINIB TAB 100 MG, LORLATINIB TAB 25 MG LUMAKRAS SOTORASIB TAB 120 MG LEUPROLIDE (1 MON) INJ 3.75 MG & NORETHINDRONE TAB 5 MG KIT, LEUPROLIDE (3 MON) INJ 11.25 MG & LUPANETA PACK NORETHINDRONE TAB 5 MG KIT LUPKYNIS VOCLOSPORIN CAP 7.9 MG LUPRON DEPOT (1-MONTH) LEUPROLIDE ACETATE FOR INJ KIT 3.75 MG, LEUPROLIDE ACETATE FOR INJ KIT 7.5 MG LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 11.25 MG, LEUPROLIDE ACETATE (3 MONTH) FOR INJ KIT 22.5 LUPRON DEPOT (3-MONTH) MG LUPRON DEPOT (4-MONTH) LEUPROLIDE ACETATE (4 MONTH) FOR INJ KIT 30 MG LUPRON DEPOT (6-MONTH) LEUPROLIDE ACETATE (6 MONTH) FOR INJ KIT 45 MG LUPRON DEPOT-PED (1- LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 11.25 MG, LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 15 MG, MONTH) LEUPROLIDE ACETATE FOR INJ PEDIATRIC KIT 7.5 MG LUPRON DEPOT-PED (3- LEUPROLIDE ACETATE (3 MONTH) FOR INJ PEDIATRIC KIT 11.25 MG, LEUPROLIDE ACETATE (3 MONTH) FOR MONTH) INJ PEDIATRIC KIT 30 MG LYNPARZA OLAPARIB TAB 100 MG, OLAPARIB TAB 150 MG LYSODREN MITOTANE TAB 500 MG HYDROXYPROGESTERONE CAPROATE IM IN OIL 250 MG/ML, HYDROXYPROGESTERONE CAPROATE SOLN MAKENA AUTO-INJECTOR 275 MG/1.1ML MATULANE PROCARBAZINE HCL CAP 50 MG CLADRIBINE TAB THERAPY PACK 10 MG (10 TABS), CLADRIBINE TAB THERAPY PACK 10 MG (4 TABS), CLADRIBINE TAB THERAPY PACK 10 MG (5 TABS), CLADRIBINE TAB THERAPY PACK 10 MG (6 TABS), MAVENCLAD CLADRIBINE TAB THERAPY PACK 10 MG (7 TABS), CLADRIBINE TAB THERAPY PACK 10 MG (8 TABS), CLADRIBINE TAB THERAPY PACK 10 MG (9 TABS) MAVYRET GLECAPREVIR-PIBRENTASVIR TAB 100-40 MG MAYZENT SIPONIMOD FUMARATE TAB 0.25 MG (BASE EQUIV), SIPONIMOD FUMARATE TAB 2 MG (BASE EQUIV) MAYZENT STARTER PACK SIPONIMOD FUMARATE TAB 0.25 MG (12) STARTER PACK TRAMETINIB DIMETHYL SULFOXIDE TAB 0.5 MG (BASE EQUIVALENT), TRAMETINIB DIMETHYL SULFOXIDE TAB MEKINIST 2 MG (BASE EQUIVALENT) MEKTOVI BINIMETINIB TAB 15 MG MENOPUR MENOTROPINS FOR SUBCUTANEOUS INJ 75 UNIT MIGLUSTAT CAP 100 MG MODERIBA RIBAVIRIN TAB 200 MG MULPLETA LUSUTROMBOPAG TAB 3 MG MYALEPT FOR SUBCUTANEOUS INJ 11.3 MG MYCAPSSA OCTREOTIDE ACETATE CAP DELAYED RELEASE 20 MG MYLERAN BUSULFAN TAB 2 MG PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 100 MCG, PARATHYROID HORMONE NATPARA (RECOMBINANT) FOR INJ CARTRIDGE 25 MCG, PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 50 MCG, PARATHYROID HORMONE (RECOMBINANT) FOR INJ CARTRIDGE 75 MCG NERATINIB MALEATE TAB 40 MG (BASE NERLYNX EQUIVALENT) NEULASTA PEGFILGRASTIM SOLN PREFILLED SYRINGE 6 MG/0.6ML

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DRUG NAME(S) GENERIC NAME NEULASTA ONPRO KIT PEGFILGRASTIM SOLN PREFILLED SYRINGE KIT 6 MG/0.6ML FILGRASTIM INJ 300 MCG/ML, FILGRASTIM INJ 480 MCG/1.6ML (300 MCG/ML), FILGRASTIM SOLN PREFILLED NEUPOGEN SYRINGE 300 MCG/0.5ML, FILGRASTIM SOLN PREFILLED SYRINGE 480 MCG/0.8ML (600 MCG/ML) NEXAVAR TOSYLATE TAB 200 MG (BASE EQUIVALENT) IXAZOMIB CITRATE CAP 2.3 MG (BASE EQUIVALENT), IXAZOMIB CITRATE CAP 3 MG (BASE EQUIVALENT), NINLARO IXAZOMIB CITRATE CAP 4 MG (BASE EQUIVALENT) NITYR TAB 10 MG, NITISINONE TAB 2 MG, NITISINONE TAB 5 MG FILGRASTIM-AAFI INJ 300 MCG/ML, FILGRASTIM-AAFI INJ 480 MCG/1.6ML (300 MCG/ML), FILGRASTIM-AAFI NIVESTYM SOLN PREFILLED SYRINGE 300 MCG/0.5ML, FILGRASTIM-AAFI SOLN PREFILLED SYRINGE 480 MCG/0.8ML SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/1.5ML, SOMATROPIN SOLUTION PEN-INJECTOR 15 NORDITROPIN FLEXPRO MG/1.5ML, SOMATROPIN SOLUTION PEN-INJECTOR 30 MG/3ML, SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/1.5ML NORTHERA DROXIDOPA CAP 100 MG, DROXIDOPA CAP 200 MG, DROXIDOPA CAP 300 MG NOURIANZ ISTRADEFYLLINE TAB 20 MG, ISTRADEFYLLINE TAB 40 MG NOVAREL CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT, CHORIONIC GONADOTROPIN FOR IM INJ 5000 UNIT NPLATE FOR INJ 125 MCG, ROMIPLOSTIM FOR INJ 250 MCG, ROMIPLOSTIM FOR INJ 500 MCG NUBEQA DAROLUTAMIDE TAB 300 MG MEPOLIZUMAB SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, MEPOLIZUMAB SUBCUTANEOUS NUCALA SOLUTION PREF SYRINGE 100 MG/ML NUTROPIN AQ NUSPIN 10 SOMATROPIN SOLUTION PEN-INJECTOR 10 MG/2ML NUTROPIN AQ NUSPIN 20 SOMATROPIN SOLUTION PEN-INJECTOR 20 MG/2ML NUTROPIN AQ NUSPIN 5 SOMATROPIN SOLUTION PEN-INJECTOR 5 MG/2ML NUZYRA OMADACYCLINE TOSYLATE TAB 150 MG (BASE EQUIVALENT) NYVEPRIA PEGFILGRASTIM-APGF SOLN PREFILLED SYRINGE 6 MG/0.6ML OCALIVA OBETICHOLIC ACID TAB 10 MG, OBETICHOLIC ACID TAB 5 MG OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML), OCTREOTIDE ACETATE INJ 1000 MCG/ML (1 MG/ML), OCTREOTIDE ACETATE OCTREOTIDE ACETATE INJ 200 MCG/ML (0.2 MG/ML), OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML), OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) ODOMZO SONIDEGIB PHOSPHATE CAP 200 MG (BASE EQUIVALENT) NINTEDANIB ESYLATE CAP 100 MG (BASE EQUIVALENT), NINTEDANIB ESYLATE CAP 150 MG (BASE OFEV EQUIVALENT) OLUMIANT TAB 1 MG, BARICITINIB TAB 2 MG SOMATROPIN FOR INJ 5.8 MG, SOMATROPIN SOLUTION CARTRIDGE 10 MG/1.5ML, SOMATROPIN SOLUTION OMNITROPE CARTRIDGE 5 MG/1.5ML ONUREG AZACITIDINE TAB 200 MG, AZACITIDINE TAB 300 MG OPSUMIT MACITENTAN TAB 10 MG ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 125 MG/ML, ABATACEPT SUBCUTANEOUS SOLN ORENCIA PREFILLED SYRINGE 50 MG/0.4ML, ABATACEPT SUBCUTANEOUS SOLN PREFILLED SYRINGE 87.5 MG/0.7ML ORENCIA CLICKJECT ABATACEPT SUBCUTANEOUS SOLN AUTO-INJECTOR 125 MG/ML TREPROSTINIL DIOLAMINE TAB ER 0.125 MG (BASE EQUIV), TREPROSTINIL DIOLAMINE TAB ER 0.25 MG (BASE ORENITRAM EQUIV), TREPROSTINIL DIOLAMINE TAB ER 1 MG (BASE EQUIV), TREPROSTINIL DIOLAMINE TAB ER 2.5 MG (BASE EQUIV), TREPROSTINIL DIOLAMINE TAB ER 5 MG (BASE EQUIV) ORGOVYX RELUGOLIX TAB 120 MG LUMACAFTOR-IVACAFTOR GRANULES PACKET 100-125 MG, LUMACAFTOR-IVACAFTOR GRANULES PACKET ORKAMBI 150-188 MG, LUMACAFTOR-IVACAFTOR TAB 100-125 MG, LUMACAFTOR-IVACAFTOR TAB 200-125 MG ORLADEYO BEROTRALSTAT HCL CAP 110 MG, BEROTRALSTAT HCL CAP 150 MG OTEZLA APREMILAST TAB 30 MG, APREMILAST TAB STARTER THERAPY PACK 10 MG & 20 MG & 30 MG OVIDREL CHORIOGONADOTROPIN ALFA INJ 250 MCG/0.5ML OXBRYTA VOXELOTOR TAB 500 MG OXERVATE CENEGERMIN-BKBJ OPHTH SOLN 0.002% (20 MCG/ML) PALFORZIA INITIAL DOSE PEANUT POWDER-DNFP STARTER PACK 0.5 & 1 & 1.5 & 3 & 6 MG ESCALATION PALFORZIA LEVEL 1 PEANUT POWDER-DNFP CAP SPRINKLE PACK 3 X 1 MG (3 MG DOSE) PALFORZIA LEVEL 10 PEANUT POWDER-DNFP PACK 2 X 20 MG & 2 X 100 MG (240 MG DOSE) PALFORZIA LEVEL 11 PEANUT ALLERGEN POWDER-DNFP MAINTENANCE PACKET 300 MG (MAINTENANCE)

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DRUG NAME(S) GENERIC NAME PALFORZIA LEVEL 11 PEANUT ALLERGEN POWDER-DNFP TITRATION PACKET 300 MG (TITRATION) PALFORZIA LEVEL 2 PEANUT POWDER-DNFP CAP SPRINKLE PACK 6 X 1 MG (6 MG DOSE) PALFORZIA LEVEL 3 PEANUT POWDER-DNFP PACK 2 X 1 MG & 10 MG (12 MG DOSE) PALFORZIA LEVEL 4 PEANUT POWDER-DNFP CAP SPRINKLE PACK 20 MG (20 MG DOSE) PALFORZIA LEVEL 5 PEANUT POWDER-DNFP CAP SPRINKLE PACK 2 X 20 MG (40 MG DOSE) PALFORZIA LEVEL 6 PEANUT POWDER-DNFP CAP SPRINKLE PACK 4 X 20 MG (80 MG DOSE) PALFORZIA LEVEL 7 PEANUT POWDER-DNFP PACK 20 MG & 100 MG (120 MG DOSE) PALFORZIA LEVEL 8 PEANUT POWDER-DNFP PACK 3 X 20 MG & 100 MG (160 MG DOSE) PALFORZIA LEVEL 9 PEANUT POWDER-DNFP PACK 2 X 100 MG (200 MG DOSE) -PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 10 MG/0.5ML, PEGVALIASE-PQPZ SUBCUTANEOUS PALYNZIQ SOLN PREF SYRINGE 2.5 MG/0.5ML, PEGVALIASE-PQPZ SUBCUTANEOUS SOLN PREF SYRINGE 20 MG/ML PEGASYS PEGINTERFERON ALFA-2A INJ 180 MCG/0.5ML, PEGINTERFERON ALFA-2A INJ 180 MCG/ML PEGASYS PROCLICK PEGINTERFERON ALFA-2A INJ 180 MCG/0.5ML PEGINTRON PEGINTERFERON ALFA-2B FOR INJ KIT 50 MCG/0.5ML PEMAZYRE PEMIGATINIB TAB 13.5 MG, PEMIGATINIB TAB 4.5 MG, PEMIGATINIB TAB 9 MG PENICILLAMINE PENICILLAMINE CAP 250 MG, PENICILLAMINE TAB 250 MG PIQRAY 200MG DAILY DOSE ALPELISIB TAB THERAPY PACK 200 MG DAILY DOSE PIQRAY 250MG DAILY DOSE ALPELISIB TAB PACK 250 MG DAILY DOSE (200 MG & 50 MG TABS) PIQRAY 300MG DAILY DOSE ALPELISIB TAB PACK 300 MG DAILY DOSE (2X150 MG TAB) PEGINTERFERON BETA-1A IM SOLN PREFILLED SYR 125 MCG/0.5ML, PEGINTERFERON BETA-1A SOLN PEN- PLEGRIDY INJECTOR 125 MCG/0.5ML, PEGINTERFERON BETA-1A SOLN PREFILLED SYRINGE 125 MCG/0.5ML PEGINTERFERON BETA-1A SOLN PEN-INJ 63 & 94 MCG/0.5ML PACK, PEGINTERFERON BETA-1A SOLN PREF SYR PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML PACK POMALIDOMIDE CAP 1 MG, POMALIDOMIDE CAP 2 MG, POMALIDOMIDE CAP 3 MG, POMALIDOMIDE CAP 4 POMALYST MG PONVORY PONESIMOD TAB 20 MG PONVORY 14-DAY STARTER PONESIMOD TAB STARTER PACK 2,3,4,5,6,7,8,9 &10 MG PACK PREGNYL W/DILUENT CHORIONIC GONADOTROPIN FOR IM INJ 10000 UNIT BENZYL ALCOHOL/NACL EPOETIN ALFA INJ 10000 UNIT/ML, EPOETIN ALFA INJ 2000 UNIT/ML, EPOETIN ALFA INJ 20000 UNIT/ML, PROCRIT EPOETIN ALFA INJ 3000 UNIT/ML, EPOETIN ALFA INJ 4000 UNIT/ML, EPOETIN ALFA INJ 40000 UNIT/ML CYSTEAMINE BITARTRATE CAP DELAYED RELEASE 25 MG (BASE EQUIV), CYSTEAMINE BITARTRATE CAP PROCYSBI DELAYED RELEASE 75 MG (BASE EQUIV), CYSTEAMINE BITARTRATE DELAYED RELEASE GRANULES PACKET 300 MG, CYSTEAMINE BITARTRATE DELAYED RELEASE GRANULES PACKET 75 MG OLAMINE POWDER PACK FOR SUSP 12.5 MG (BASE EQ), ELTROMBOPAG OLAMINE POWDER PACK FOR SUSP 25 MG (BASE EQUIV), ELTROMBOPAG OLAMINE TAB 12.5 MG (BASE EQUIV), ELTROMBOPAG PROMACTA OLAMINE TAB 25 MG (BASE EQUIV), ELTROMBOPAG OLAMINE TAB 50 MG (BASE EQUIV), ELTROMBOPAG OLAMINE TAB 75 MG (BASE EQUIV) PULMOZYME DORNASE ALFA INHAL SOLN 1 MG/ML PURIXAN MERCAPTOPURINE SUSP 2000 MG/100ML (20 MG/ML) QINLOCK RIPRETINIB TAB 50 MG QUTENZA CAPSAICIN PATCH 8% & CLEANSING GEL KIT RAVICTI LIQUID 1.1 GM/ML INTERFERON BETA-1A SOLN PREF SYR 22 MCG/0.5ML (12MU/ML), INTERFERON BETA-1A SOLN PREF SYR 44 REBIF MCG/0.5ML (24MU/ML) INTERFERON BETA-1A SOLN AUTO-INJ 22 MCG/0.5ML (12MU/ML), INTERFERON BETA-1A SOLN AUTO-INJ 44 REBIF REBIDOSE MCG/0.5ML (24MU/ML) REBIF REBIDOSE TITRATION INTERFERON BETA-1A AUTO-INJ 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML PACK REBIF TITRATION PACK INTERFERON BETA-1A PREF SYR 6X8.8 MCG/0.2ML & 6X22 MCG/0.5ML -AAMT FOR SUBCUTANEOUS INJ 25 MG, LUSPATERCEPT-AAMT FOR SUBCUTANEOUS INJ 75 REBLOZYL MG EPOETIN ALFA-EPBX INJ 10000 UNIT/ML, EPOETIN ALFA-EPBX INJ 2000 UNIT/ML, EPOETIN ALFA-EPBX INJ RETACRIT 20000 UNIT/ML, EPOETIN ALFA-EPBX INJ 3000 UNIT/ML, EPOETIN ALFA-EPBX INJ 4000 UNIT/ML, EPOETIN ALFA-EPBX INJ 40000 UNIT/ML Blue Cross Blue Shield of North Dakota Updated 9/1/2021 Page 8 of 12 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change Blue Cross Blue Shield of North Dakota Specialty Drug List

DRUG NAME(S) GENERIC NAME RETEVMO SELPERCATINIB CAP 40 MG, SELPERCATINIB CAP 80 MG SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML, SILDENAFIL CITRATE IV SOLN 10 MG/12.5ML (BASE REVATIO EQUIVALENT), SILDENAFIL CITRATE TAB 20 MG REVCOVI ELAPEGADEMASE-LVLR IM SOLN 2.4 MG/1.5ML (1.6 MG/ML) CAP 10 MG, LENALIDOMIDE CAP 15 MG, LENALIDOMIDE CAP 20 MG, LENALIDOMIDE CAP 25 REVLIMID MG, LENALIDOMIDE CAP 5 MG, LENALIDOMIDE CAPS 2.5 MG RIBASPHERE RIBAVIRIN CAP 200 MG, RIBAVIRIN TAB 200 MG, RIBAVIRIN TAB 400 MG, RIBAVIRIN TAB 600 MG RIBAVIRIN TAB PACK 200 MG & 400 MG (600 MG DAILY DOSE), RIBAVIRIN TAB PACK 400 MG & 600 MG (1000 RIBASPHERE RIBAPAK MG DAILY DOSE), RIBAVIRIN TAB THERAPY PACK 400 MG (800 MG DAILY DOSE), RIBAVIRIN TAB THERAPY PACK 600 MG (1200 MG DAILY DOSE) RIBAVIRIN RIBAVIRIN CAP 200 MG, RIBAVIRIN TAB 200 MG RILUTEK RILUZOLE TAB 50 MG RILUZOLE RILUZOLE TAB 50 MG RINVOQ TAB ER 24HR 15 MG ROZLYTREK ENTRECTINIB CAP 100 MG, ENTRECTINIB CAP 200 MG RUCAPARIB CAMSYLATE TAB 200 MG (BASE EQUIVALENT), RUCAPARIB CAMSYLATE TAB 250 MG (BASE RUBRACA EQUIVALENT), RUCAPARIB CAMSYLATE TAB 300 MG (BASE EQUIVALENT) RUCONEST C1 ESTERASE INHIBITOR (RECOMBINANT) FOR IV INJ 2100 UNIT RUZURGI AMIFAMPRIDINE TAB 10 MG RYDAPT CAP 25 MG SABRIL VIGABATRIN POWD PACK 500 MG, VIGABATRIN TAB 500 MG SAIZEN SOMATROPIN (NON-REFRIGERATED) FOR INJ 5 MG, SOMATROPIN (NON-REFRIGERATED) FOR INJ 8.8 MG SAMSCA TOLVAPTAN TAB 15 MG, TOLVAPTAN TAB 30 MG OCTREOTIDE ACETATE INJ 100 MCG/ML (0.1 MG/ML), OCTREOTIDE ACETATE INJ 50 MCG/ML (0.05 MG/ML), SANDOSTATIN OCTREOTIDE ACETATE INJ 500 MCG/ML (0.5 MG/ML) OCTREOTIDE ACETATE FOR IM INJ KIT 10 MG, OCTREOTIDE ACETATE FOR IM INJ KIT 20 MG, OCTREOTIDE SANDOSTATIN LAR DEPOT ACETATE FOR IM INJ KIT 30 MG SAPROPTERIN SAPROPTERIN DIHYDROCHLORIDE POWDER PACKET 100 MG, SAPROPTERIN DIHYDROCHLORIDE POWDER DIHYDROCHLORIDE PACKET 500 MG, SAPROPTERIN DIHYDROCHLORIDE TAB 100 MG CINACALCET HCL TAB 30 MG (BASE EQUIV), CINACALCET HCL TAB 60 MG (BASE EQUIV), CINACALCET HCL TAB SENSIPAR 90 MG (BASE EQUIV) SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 4 MG, SOMATROPIN (NON-REFRIGERATED) SEROSTIM FOR SUBCUTANEOUS INJ 5 MG, SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 6 MG PASIREOTIDE DIASPARTATE INJ 0.3 MG/ML (BASE EQUIV), PASIREOTIDE DIASPARTATE INJ 0.6 MG/ML (BASE SIGNIFOR EQUIV), PASIREOTIDE DIASPARTATE INJ 0.9 MG/ML (BASE EQUIV) SIKLOS HYDROXYUREA TAB 100 MG, HYDROXYUREA TAB 1000 MG SILDENAFIL SILDENAFIL CITRATE IV SOLN 10 MG/12.5ML (BASE EQUIVALENT) SILDENAFIL CITRATE SILDENAFIL CITRATE FOR SUSPENSION 10 MG/ML, SILDENAFIL CITRATE TAB 20 MG SILIQ BRODALUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 210 MG/1.5ML GOLIMUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 100 MG/ML, GOLIMUMAB SUBCUTANEOUS SOLN SIMPONI AUTO-INJECTOR 50 MG/0.5ML, GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 100 MG/ML, GOLIMUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 50 MG/0.5ML SIRTURO BEDAQUILINE FUMARATE TAB 100 MG (BASE EQUIV), BEDAQUILINE FUMARATE TAB 20 MG (BASE EQUIV) RISANKIZUMAB-RZAA SOL PREFILLED SYRINGE 2 X 75 MG/0.83ML KIT, RISANKIZUMAB-RZAA SOLN PREFILLED SKYRIZI SYRINGE 150 MG/ML SKYRIZI PEN RISANKIZUMAB-RZAA SOLN AUTO-INJECTOR 150 MG/ML SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE ORAL POWDER 3 GM/TEASPOONFUL, SODIUM PHENYLBUTYRATE TAB 500 MG SOFOSBUVIR/VELPATASVIR SOFOSBUVIR-VELPATASVIR TAB 400-100 MG LANREOTIDE ACETATE EXTENDED RELEASE INJ 120 MG/0.5ML, LANREOTIDE ACETATE EXTENDED RELEASE INJ SOMATULINE DEPOT 60 MG/0.2ML, LANREOTIDE ACETATE EXTENDED RELEASE INJ 90 MG/0.3ML PEGVISOMANT FOR INJ 10 MG (AS PROTEIN), PEGVISOMANT FOR INJ 15 MG (AS PROTEIN), PEGVISOMANT SOMAVERT FOR INJ 20 MG (AS PROTEIN), PEGVISOMANT FOR INJ 25 MG (AS PROTEIN), PEGVISOMANT FOR INJ 30 MG (AS PROTEIN) SOFOSBUVIR PELLET PACK 150 MG, SOFOSBUVIR PELLET PACK 200 MG, SOFOSBUVIR TAB 200 MG, SOVALDI SOFOSBUVIR TAB 400 MG SPRAVATO 84MG DOSE ESKETAMINE HCL NASAL SOLN 28 MG/DEVICE X 3 (84 MG DOSE PACK)

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DRUG NAME(S) GENERIC NAME DASATINIB TAB 100 MG, DASATINIB TAB 140 MG, DASATINIB TAB 20 MG, DASATINIB TAB 50 MG, DASATINIB SPRYCEL TAB 70 MG, DASATINIB TAB 80 MG USTEKINUMAB INJ 45 MG/0.5ML, USTEKINUMAB SOLN PREFILLED SYRINGE 45 MG/0.5ML, USTEKINUMAB STELARA SOLN PREFILLED SYRINGE 90 MG/ML STIVARGA REGORAFENIB TAB 40 MG SUBCUTANEOUS INJ 18 MG/0.45ML, ASFOTASE ALFA SUBCUTANEOUS INJ 28 MG/0.7ML, STRENSIQ ASFOTASE ALFA SUBCUTANEOUS INJ 40 MG/ML, ASFOTASE ALFA SUBCUTANEOUS INJ 80 MG/0.8ML SUCRAID SOLN 8500 UNIT/ML MALATE CAP 12.5 MG (BASE EQUIVALENT), SUNITINIB MALATE CAP 25 MG (BASE EQUIVALENT), SUTENT SUNITINIB MALATE CAP 37.5 MG (BASE EQUIVALENT), SUNITINIB MALATE CAP 50 MG (BASE EQUIVALENT) PEGINTERFERON ALFA-2B FOR INJ KIT 200 MCG, PEGINTERFERON ALFA-2B FOR INJ KIT 300 MCG, SYLATRON PEGINTERFERON ALFA-2B FOR INJ KIT 600 MCG TEZACAFTOR-IVACAFTOR 100-150 MG & IVACAFTOR 150 MG TAB TBPK, TEZACAFTOR-IVACAFTOR 50-75 MG SYMDEKO & IVACAFTOR 75 MG TAB TBPK SYNAREL NAFARELIN ACETATE NASAL SOLN 2 MG/ML (200 MCG/ACT) (BASE EQ) SYPRINE TRIENTINE HCL CAP 250 MG TABRECTA CAPMATINIB HCL TAB 150 MG, CAPMATINIB HCL TAB 200 MG TADALAFIL TADALAFIL TAB 20 MG (PAH) DABRAFENIB MESYLATE CAP 50 MG (BASE EQUIVALENT), DABRAFENIB MESYLATE CAP 75 MG (BASE TAFINLAR EQUIVALENT) OSIMERTINIB MESYLATE TAB 40 MG (BASE EQUIVALENT), OSIMERTINIB MESYLATE TAB 80 MG (BASE TAGRISSO EQUIVALENT) TAKHZYRO LANADELUMAB-FLYO INJ 300 MG/2ML (150 MG/ML) IXEKIZUMAB SUBCUTANEOUS SOLN AUTO-INJECTOR 80 MG/ML, IXEKIZUMAB SUBCUTANEOUS SOLN TALTZ PREFILLED SYRINGE 80 MG/ML TALAZOPARIB TOSYLATE CAP 0.25 MG (BASE EQUIVALENT), TALAZOPARIB TOSYLATE CAP 1 MG (BASE TALZENNA EQUIVALENT) ERLOTINIB HCL TAB 100 MG (BASE EQUIVALENT), ERLOTINIB HCL TAB 150 MG (BASE EQUIVALENT), TARCEVA ERLOTINIB HCL TAB 25 MG (BASE EQUIVALENT) TARGRETIN BEXAROTENE CAP 75 MG, BEXAROTENE GEL 1% NILOTINIB HCL CAP 150 MG (BASE EQUIVALENT), NILOTINIB HCL CAP 200 MG (BASE EQUIVALENT), NILOTINIB TASIGNA HCL CAP 50 MG (BASE EQUIVALENT) FOSTAMATINIB DISODIUM TAB 100 MG (BASE EQUIVALENT), FOSTAMATINIB DISODIUM TAB 150 MG (BASE TAVALISSE EQUIVALENT) TAZVERIK TAZEMETOSTAT HBR TAB 200 MG DIMETHYL FUMARATE CAPSULE DELAYED RELEASE 120 MG, DIMETHYL FUMARATE CAPSULE DELAYED TECFIDERA RELEASE 240 MG TECFIDERA STARTER PACK DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG TEGSEDI INOTERSEN SOD SUBCUTANEOUS PREF SYR 284 MG/1.5ML (BASE EQ) TEMOZOLOMIDE CAP 100 MG, TEMOZOLOMIDE CAP 140 MG, TEMOZOLOMIDE CAP 180 MG, TEMODAR TEMOZOLOMIDE CAP 20 MG, TEMOZOLOMIDE CAP 250 MG, TEMOZOLOMIDE CAP 5 MG TEMOZOLOMIDE CAP 100 MG, TEMOZOLOMIDE CAP 140 MG, TEMOZOLOMIDE CAP 180 MG, TEMOZOLOMIDE TEMOZOLOMIDE CAP 20 MG, TEMOZOLOMIDE CAP 250 MG, TEMOZOLOMIDE CAP 5 MG TEPMETKO TEPOTINIB HCL TAB 225 MG TERIPARATIDE TERIPARATIDE (RECOMBINANT) SOLN PEN-INJ 620 MCG/2.48ML TETRABENAZINE TETRABENAZINE TAB 12.5 MG, TETRABENAZINE TAB 25 MG THALIDOMIDE CAP 100 MG, THALIDOMIDE CAP 150 MG, THALIDOMIDE CAP 200 MG, THALIDOMIDE CAP 50 THALOMID MG TIBSOVO IVOSIDENIB TAB 250 MG TIGLUTIK RILUZOLE SUSP 50 MG/10ML TOBI TOBRAMYCIN NEBU SOLN 300 MG/5ML TOBI PODHALER TOBRAMYCIN INHAL CAP 28 MG TOBRAMYCIN TOBRAMYCIN NEBU SOLN 300 MG/4ML, TOBRAMYCIN NEBU SOLN 300 MG/5ML TOLVAPTAN TOLVAPTAN TAB 15 MG, TOLVAPTAN TAB 30 MG TRACLEER BOSENTAN TAB 125 MG, BOSENTAN TAB 62.5 MG, BOSENTAN TAB FOR ORAL SUSP 32 MG TRELSTAR MIXJECT TRIPTORELIN PAMOATE FOR IM SUSP 22.5 MG

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DRUG NAME(S) GENERIC NAME TREMFYA GUSELKUMAB SOLN PEN-INJECTOR 100 MG/ML, GUSELKUMAB SOLN PREFILLED SYRINGE 100 MG/ML TRETINOIN TRETINOIN CAP 10 MG TRIENTINE HYDROCHLORIDE TRIENTINE HCL CAP 250 MG ELEXACAF-TEZACAF-IVACAF 100-50-75 MG &IVACAFTOR 150 MG TBPK, ELEXACAF-TEZACAF-IVACAF 50-25- TRIKAFTA 37.5 MG & IVACAFTOR 75 MG TBPK INFIGRATINIB PHOS CAP PACK 100 & 25 MG (125 MG DAILY DOSE), INFIGRATINIB PHOS CAP THER PACK 100 MG (100 MG DAILY DOSE), INFIGRATINIB PHOS CAP THER PACK 2 X 25 MG (50 MG DAILY DOSE), INFIGRATINIB TRUSELTIQ PHOS CAP THER PACK 3 X 25 MG (75 MG DAILY DOSE), INFIGRATINIB PHOS CAP THER PACK 2 X 25 MG (50 MG DAILY DOSE) TUKYSA TUCATINIB TAB 150 MG, TUCATINIB TAB 50 MG TURALIO PEXIDARTINIB HCL CAP 200 MG (BASE EQUIVALENT) TYKERB LAPATINIB DITOSYLATE TAB 250 MG (BASE EQUIV) TYMLOS ABALOPARATIDE SUBCUTANEOUS SOLN PEN-INJECTOR 3120 MCG/1.56ML TYVASO TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML TYVASO REFILL TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML TYVASO STARTER TREPROSTINIL INHALATION SOLUTION 0.6 MG/ML UDENYCA PEGFILGRASTIM-CBQV SOLN PREFILLED SYRINGE 6 MG/0.6ML UKONIQ UMBRALISIB TOSYLATE TAB 200 MG SELEXIPAG TAB 1000 MCG, SELEXIPAG TAB 1200 MCG, SELEXIPAG TAB 1400 MCG, SELEXIPAG TAB 1600 MCG, UPTRAVI SELEXIPAG TAB 200 MCG, SELEXIPAG TAB 400 MCG, SELEXIPAG TAB 600 MCG, SELEXIPAG TAB 800 MCG, SELEXIPAG TAB THERAPY PACK 200 MCG (140) & 800 MCG (60) VALCHLOR MECHLORETHAMINE HCL GEL 0.016% (BASE EQUIVALENT) VECAMYL MECAMYLAMINE HCL TAB 2.5 MG VENCLEXTA VENETOCLAX TAB 10 MG, VENETOCLAX TAB 100 MG, VENETOCLAX TAB 50 MG VENCLEXTA STARTING PACK VENETOCLAX TAB THERAPY STARTER PACK 10 & 50 & 100 MG VENTAVIS ILOPROST INHALATION SOLUTION 10 MCG/ML, ILOPROST INHALATION SOLUTION 20 MCG/ML VERZENIO ABEMACICLIB TAB 100 MG, ABEMACICLIB TAB 150 MG, ABEMACICLIB TAB 200 MG, ABEMACICLIB TAB 50 MG VIEKIRA PAK OMBITAS-PARITAPRE-RITON & DASAB TAB PAK 12.5-75-50 & 250 MG VIGABATRIN VIGABATRIN POWD PACK 500 MG, VIGABATRIN TAB 500 MG VIGADRONE VIGABATRIN POWD PACK 500 MG LAROTRECTINIB SULFATE CAP 100 MG (BASE EQUIVALENT), LAROTRECTINIB SULFATE CAP 25 MG (BASE VITRAKVI EQUIVALENT), LAROTRECTINIB SULFATE ORAL SOLN 20 MG/ML (BASE EQUIVALENT) VIZIMPRO DACOMITINIB TAB 15 MG, DACOMITINIB TAB 30 MG, DACOMITINIB TAB 45 MG VOSEVI SOFOSBUVIR-VELPATASVIR-VOXILAPREVIR TAB 400-100-100 MG VOTRIENT PAZOPANIB HCL TAB 200 MG (BASE EQUIV) DIROXIMEL FUMARATE CAPSULE DELAYED RELEASE 231 MG, DIROXIMEL FUMARATE CAPSULE DR STARTER VUMERITY BOTTLE 231 MG VYLEESI BREMELANOTIDE ACET SUBCUTANEOUS SOLN AUTO-INJ 1.75 MG/0.3ML VYNDAMAX TAFAMIDIS CAP 61 MG VYNDAQEL TAFAMIDIS MEGLUMINE (CARDIAC) CAP 20 MG WAKIX PITOLISANT HCL TAB 17.8 MG (BASE EQUIVALENT), PITOLISANT HCL TAB 4.45 MG (BASE EQUIVALENT) XALKORI CRIZOTINIB CAP 200 MG, CRIZOTINIB CAP 250 MG CITRATE ORAL SOLN 1 MG/ML (BASE EQUIVALENT), TOFACITINIB CITRATE TAB 10 MG (BASE XELJANZ EQUIVALENT), TOFACITINIB CITRATE TAB 5 MG (BASE EQUIVALENT) TOFACITINIB CITRATE TAB ER 24HR 11 MG (BASE EQUIVALENT), TOFACITINIB CITRATE TAB ER 24HR 22 MG XELJANZ XR (BASE EQUIVALENT) XELODA CAPECITABINE TAB 150 MG, CAPECITABINE TAB 500 MG XENAZINE TETRABENAZINE TAB 12.5 MG, TETRABENAZINE TAB 25 MG XENLETA LEFAMULIN ACETATE TAB 600 MG XERMELO TELOTRISTAT ETHYL TAB 250 MG (AS TELOTRISTAT ETIPRATE) OMALIZUMAB SUBCUTANEOUS SOLN PREFILLED SYRINGE 75 MG/0.5ML, OMALIZUMAB SUBCUTANEOUS XOLAIR SOLN PREFILLED SYRINGE 150 MG/ML XOSPATA GILTERITINIB FUMARATE TABLET 40 MG (BASE EQUIVALENT) SELINEXOR TAB THERAPY PACK 40 MG (40 MG ONCE WEEKLY), SELINEXOR TAB THERAPY PACK 40 MG (40 MG XPOVIO TWICE WEEKLY), SELINEXOR TAB THERAPY PACK 40 MG (80 MG ONCE WEEKLY), SELINEXOR TAB THERAPY PACK 50 MG (100 MG ONCE WEEKLY), SELINEXOR TAB THERAPY PACK 60 MG (60 MG ONCE WEEKLY)

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DRUG NAME(S) GENERIC NAME XPOVIO 100 MG ONCE SELINEXOR TAB THERAPY PACK 20 MG (100 MG ONCE WEEKLY) WEEKLY XPOVIO 40 MG ONCE SELINEXOR TAB THERAPY PACK 20 MG (40 MG ONCE WEEKLY) WEEKLY XPOVIO 40 MG TWICE SELINEXOR TAB THERAPY PACK 20 MG (40 MG TWICE WEEKLY) WEEKLY XPOVIO 60 MG ONCE SELINEXOR TAB THERAPY PACK 20 MG (60 MG ONCE WEEKLY) WEEKLY XPOVIO 60 MG TWICE SELINEXOR TAB THERAPY PACK 20 MG (60 MG TWICE WEEKLY) WEEKLY XPOVIO 80 MG ONCE SELINEXOR TAB THERAPY PACK 20 MG (80 MG ONCE WEEKLY) WEEKLY XPOVIO 80 MG TWICE SELINEXOR TAB THERAPY PACK 20 MG (80 MG TWICE WEEKLY) WEEKLY XTANDI ENZALUTAMIDE CAP 40 MG, ENZALUTAMIDE TAB 40 MG, ENZALUTAMIDE TAB 80 MG XURIDEN ORAL GRANULES PACKET 2 GM XYREM SODIUM OXYBATE ORAL SOLUTION 500 MG/ML XYWAV CALCIUM, MAG, POTASSIUM, & SOD OXYBATES ORAL SOLN 500 MG/ML YONSA ABIRATERONE ACETATE TAB 125 MG FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE 300 MCG/0.5ML, FILGRASTIM-SNDZ SOLN PREFILLED SYRINGE ZARXIO 480 MCG/0.8ML ZAVESCA MIGLUSTAT CAP 100 MG ZEJULA NIRAPARIB TOSYLATE CAP 100 MG (BASE EQUIVALENT) ZELBORAF VEMURAFENIB TAB 240 MG ZEPATIER ELBASVIR-GRAZOPREVIR TAB 50-100 MG ZEPOSIA OZANIMOD HCL CAP 0.92 MG ZEPOSIA 7-DAY STARTER OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG PACK ZEPOSIA STARTER KIT OZANIMOD CAP PACK 4 X 0.23 MG & 3 X 0.46 MG & 30 X 0.92 MG ZIEXTENZO PEGFILGRASTIM-BMEZ SOLN PREFILLED SYRINGE 6 MG/0.6ML ZOKINVY LONAFARNIB CAP 50 MG, LONAFARNIB CAP 75 MG ZOLINZA VORINOSTAT CAP 100 MG ZOMACTON SOMATROPIN FOR INJ 10 MG, SOMATROPIN FOR SUBCUTANEOUS INJ 5 MG ZORBTIVE SOMATROPIN (NON-REFRIGERATED) FOR SUBCUTANEOUS INJ 8.8 MG ZYDELIG IDELALISIB TAB 100 MG, IDELALISIB TAB 150 MG ZYKADIA CERITINIB CAP 150 MG, CERITINIB TAB 150 MG ZYTIGA ABIRATERONE ACETATE TAB 250 MG, ABIRATERONE ACETATE TAB 500 MG

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