January 2025 Pharmacy Policies Updates

Applies to both Commercial and Medicaid Expansion

Blue Cross Blue Shield of North Dakota (BCBSND) continually develops and revises pharmacy policies in response to rapidly changing pharmaceutical requirements. Our commitment is to update the provider community as pharmacy policies are adopted and/or revised.

Medicaid Expansion Updates
Note: There may be corresponding policies for our Commercial lines of business.


The following Medicaid Expansion medical drug policies are new and effective Mar. 1, 2025:

  • Certolizumab (Cimzia)
  • Cipaglucosidase alfa-atga (Pombiliti)
  • Denileukin diftitox-cxdl (Lymphir)


The following Medicaid Expansion medical drug policies are revised and effective Feb. 1, 2025:

  • Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
  • Chimeric Antigen Receptor Therapy for Multiple Myeloma
  • Immune Globulin Therapy
  • Monoclonal Antibodies for the Treatment of Eosinophilic Conditions


The following Medicaid Expansion medical drug policies are revised and effective Mar. 1, 2025:

  • Abatacept (Orencia) IV
  • ADAMTS13, recombinant-krhn (Adzynma)
  • Amivantamab-vmjw (Rybrevant)
  • Bevacizumab (Avastin) and Bevacizumab Biosimilars
  • Golimumab (Simponi Aria)
  • Ibalizumab-uiyk (Trogarzo)
  • Imetelstat (Rytelo)
  • Intravitreal Injections
    • Added aflibercept-ayyh (Pavblu)
  • Isatuximab-irfc (Sarclisa)
  • Lifileucel (Amtagvi)
  • Luspatercept (Reblozyl)
  • Obinutuzumab (Gazyva)
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
  • Teplizumab-mzwv (Tzield)
  • Treatment of Hereditary Amyloidosis
  • Vedolizumab (Entyvio)


The following Medicaid Expansion medical drug policy has a coding change effective Jan. 1, 2025:

  • Bendamustine


The following Medicaid Expansion medical drug policy will be retired on Feb. 28, 2025:

  • Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies


The following Medicaid Expansion medical drug policies were reviewed with no clinical content change:

  • Rozanolixizumab-noli (Rystiggo)
  • Velmanase alfa-tycv (Lamzede)


Commercial Updates

The following Commercial medical drug policy has a coding change effective Jan. 1, 2025:

  • Continuous Glucose Monitoring Systems


The following Commercial medical drug policies are new and effective Feb. 1, 2025:
*Please reference www.gatewaypa.com/policydisplay/52 on or after Feb. 1, 2025

  • Bizengri
  • Opdivo Qvantig
  • Ryoncil
  • Steqeyma IV
  • Unloxcyt
  • Yesintek IV
  • Ziihera


The following Commercial prior authorization medical drug policies have revisions:
*Please reference www.gatewaypa.com/policydisplay/52

  • Abecma
  • Adakveo
  • Adcetris
  • Adzynma
  • Aphexda
  • Bavencio
  • Beqvez
  • Bevacizumab (oncology indications)
  • Breyanzi
  • Briumvi
  • Carvykti
  • Casgevy
  • Cinqair
  • Danyelza
  • Darzalex IV
  • Erbitux
  • Erwinaze
  • Givlaari
  • Hemgenix
  • Imdelltra
  • Imfinzi
  • Imjudo
  • Jemperli
  • Keytruda
  • Kimmtrak
  • Kymriah
  • Lantidra
  • Lemtrada
  • Leqembi
  • Libtayo
  • Loqtorzi
  • Lumoxiti
  • Lunsumio
  • Luxturna
  • Lyfgenia
  • Mozobil
  • Natalizumab
  • Ocrevus IV
  • Oncaspar
  • Opdivo
  • Paclitaxel Albumin-Bound
  • Pemetrexed
  • Polivy
  • Rituximab IV
  • Roctavian
  • Romidepsin
  • Rylaze
  • Spinraza
  • Tecartus
  • Tecentriq IV
  • Tevimbra
  • Trastuzumab IV
  • Trodelvy
  • Tzield
  • Ustekinumab
  • Yervoy
  • Yescarta
  • Zolgensma
  • Zynyz


The following Commercial post service claim edit medical drug policies have revisions:
*Please reference: www.gatewaypa.com/policydisplay/52

  • Asparlas
  • Besponsa
  • Botox
  • Daxxify
  • Dysport
  • Fulvestrant
  • Myobloc
  • Trogarzo
  • Xeomin


The following Commercial medical drug policy will be retired on Jan. 15, 2025:

  • Spravato

The following are new retail pharmacy Utilization Management programs:

  • Duvyzat Prior Authorization with Quantity Limit
    • Effective Feb. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
  • IL-31 Inhibitor Prior Authorization with Quantity Limit
    • Effective Apr. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
  • Sohonos Prior Authorization with Quantity Limit
    • Effective Apr. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies


Questions?
Contact the appropriate Customer Service Provider Center: Commercial: 1-800-368-2312 or Medicaid Expansion: 1-833-777-5779.