Blue Cross Blue Shield of North Dakota Non-Payable Drug List Non-Payable Drug- A Prescription Medication or Drug that is not covered. Both brand name drugs and generic equivalents are Non-Payable. Brand name drugs and generic equivalents with a repackager National Drug REPACKAGED DRUGS- Code (NDC) are Non-Payable Brand name drugs and generic equivalents not approved by the FDA are Non- NON-FDA APPROVED DRUGS Payable OTHER NON-PAYABLE DRUGS DRUG LABEL NAME GENERIC DRUG NAME AIRDUO FLUTICASONE PROPIONATE/SALMETEROL ALBUTEROL SULFATE HFA (Prasco Laboratories) ALBUTEROL SULFATE ALLEGRA FEXOFENADINE ALLEGRA-D FEXOFENADINE/PSEUDOEPHEDRINE ALLERGENIC EXTRACTS ALLERGENIC EXTRACTS AMONDYS 45 CASIMERSEN IV AUVI-Q EPINEPHRINE AVAGE TAZAROTENE (FACIAL WRINKLES) AZESCO PRENATAL VITAMIN W/FE CLUCONATE – FA BONJESTA DOXYLAMINE-PYRIDOXINE BOTOX COSMETIC ONABOTULINUMTOXINA (COSMETIC) CARBINOXAMINE (Foxland Pharmaceuticals) CARBINOXAMINE CHLORZOXAZONE 250 MG TAB CHLORZOXAZONE CLARINEX DESLORATADINE CLARINEX-D DESLORATADINE/PSEUDOEPHEDRINE CLARITIN LORATADINE CLARITIN-D LORATADINE/PSEUDOEPHEDRINE CLEMASTINE CLEMASTINE FUMARATE CONSENSI AMLODIPINE BESYLATE-CELECOXIB DAKLINZA DACLATASVIR DICLEGIS DOXYLAMINE-PYRIDOXINE DOXYLAMINE-PYRIDOXINE DOXYLAMINE-PYRIDOXINE DUEXIS IBUPROFEN-FAMOTIDINE ELURYNG ETONOGESTREL/ETHINYL ESTRADIOL VAGINAL RING ETONOGESTREL/ETHINYL ESTRADIOL VAGINAL RING ETONOGESTREL/ETHINYL ESTRADIOL VAGINAL RING EXONDYS 51 ETEPLIRSEN FENOPROFEN CALCIUM CAP 200 MG FENOPROFEN Blue Cross Blue Shield of North Dakota Updated 9/1/21 Page 1 of 3 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change Blue Cross Blue Shield of North Dakota Non-Payable Drug List OTHER NON-PAYABLE DRUGS FENORTHO CAP 200 MG FENOPROFEN FLUTICASONE PROPIONATE/SALMETEROL DISKUS FLUTICASONE PROPIONATE/SALMETEROL DISKUS GLATOPA GLATIRAMER GLYCOPYRROLATE TAB (Foxland Pharmaceuticals) GLYCOPYRROLATE TAB INCIVEK TELAPREVIR IVERMECTIN CREAM IVERMECTIN CREAM JENLIVA PRENATAL MULTIVITAMINS & MINEALS W/IRON & FA KELARX SCAR TREATMENT PRODUCTS - GEL LACTULOSE ORAL CRYSTAL PACKETS (Foxland LACTULOSE ORAL CRYSTAL PACKETS Pharmaceuticals) LATISSE BIMATOPROST NAPROXEN-ESOMEPRAZOLE NAPROXEN-ESOMEPRAZOLE PERLANE HYALURONIC ACID PNV 20-1 PRENATAL VIT W/FE BISGLYC CHELATE - FA PREGEN DHA PRENATAL MV & MIN W/FE CARBONYL-FA-DHA PREGENNA PRENATAL VIT W/FE BISGLYC CHELATE - FA PROAIR DIGIHALER ALBUTEROL SULFATE AEROSOL POWDER PROAIR HFA ALBUTEROL SULFATE PROPECIA FINASTERIDE (ALOPECIA) 1 mg PROTHELIAL SUCRALFATE-MALATE PASTE PROVENTIL HFA ALBUTEROL SULFATE QUTENZA CAPSAICIN PATCH 8% & CLEANSING GEL KIT REFISSA TRETINOIN (FACIAL WRINKLES) RENOVA TRETINOIN (FACIAL WRINKLES) RESTYLANE HYALURONIC ACID SCARCIN GEL SCAR TREATMENT PRODUCTS - GEL SCARSILK GEL SCAR TREATMENT PRODUCTS - GEL SEMPREX-D ACRIVASTINE/PSEUDOEPHEDRINE TECHNIVIE OMBITASVIR/PARITAPREVIR/RITONAVIR TRIMIX PAPAVERINE/PHENTOLAMINE/ALPROSTADIL TRINAZ PRENATAL VITAMIN W/FE CLUCONATE – FA VANIQA EFLORNITHINE VICTRELIS BOCEPREVIR Blue Cross Blue Shield of North Dakota Updated 9/1/21 Page 2 of 3 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change Blue Cross Blue Shield of North Dakota Non-Payable Drug List OTHER NON-PAYABLE DRUGS VIEKIRA PAK/VIEKIRA XR DASABUVIR; OMBITASVIR/PARITAPREVIR/RITONAVIR VIMOVO NAPROXEN-ESOMEPRAZOLE V-GO V-GO 20, V-GO 30, V-G0 40 KIT VILTEPSO VILTOLARSEN VYONDYS 53 GOLODIRSEN WIXELA FLUTICASONE PROPIONATE/SALMETEROL XYZAL LEVOCETIRIZINE YOSPRALA ASPIRIN-OMEPRAZOLE ZALVIT PRENATAL VITAMIN W/FE CLUCONATE – FA ZYRTEC CETIRIZINE ZYRTEC-D CETIRIZINE/PSEUDOEPHEDRINE *For benefits administered by Prime Therapeutics LLC. Prime Therapeutics is an independent provider that assists in the administration of BCBSND's pharmacy benefits management on behalf of Blue Cross Blue Shield of North Dakota Blue Cross Blue Shield of North Dakota Updated 9/1/21 Page 3 of 3 An Independent Licensee of the Blue Cross and Blue Shield Association Information subject to change .