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Blue Cross Blue Shield of North Dakota Specialty Drug List Specialty Drug – medications 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 INTERFERON 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 INTERFERON ALFA-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 DARBEPOETIN ALFA 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 BELIMUMAB 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 Blue Cross Blue Shield of North Dakota Updated 9/1/2021 Page 1 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 BRONCHITOL TOLERANCE MANNITOL INHAL CAP 40 MG TEST BRUKINSA ZANUBRUTINIB CAP 80 MG BUPHENYL SODIUM PHENYLBUTYRATE 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 CARGLUMIC ACID TAB 200 MG CAYSTON AZTREONAM LYSINE FOR INHAL SOLN 75 MG (BASE EQUIVALENT) CERDELGA ELIGLUSTAT 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 GLATIRAMER ACETATE 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 CYSTEAMINE 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 Blue Cross Blue Shield of North Dakota Updated 9/1/2021 Page 2 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 DIMETHYL FUMARATE DIMETHYL FUMARATE CAPSULE DR STARTER PACK 120 MG & 240 MG STARTERPACK DOJOLVI TRIHEPTANOIN 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) ETANERCEPT 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 GLUTAMINE (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 EPOETIN ALFA 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
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