July 2024 Pharmacy Policies Updates

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.

The following medical drug policies are new effective September 2024:

  • Imetelstat (Rytelo)
  • Tarlatamab-dlle (Imdelltra)


The following medical drug policies were revised:

  • Alemtuzumab (Lemtrada) – Commercial only
  • Bendamustine (Treanda, Bendeka, Belrapzo)
  • Carfilzomib (Kyprolis)
  • Continuous Glucose Monitoring Systems – Commercial only
  • Denosumab – Commercial only
  • Edaravone (Radicava) – Commercial only
  • Exagamglogene autotemcel (Casgevy) – Commercial only
  • Fam-trastuzumab Deruxtecan-nxki (Enhertu)
  • Immune Globulin Therapy
  • Infliximab – Commercial only
  • Mirikizumab-mrkz (Omvoh) IV – Commercial only
  • Natalizumab – Commercial only
  • Ocrelizumab (Ocrevus) – Commercial only
  • Pertuzumab (Perjeta)
  • Pharmacologic Treatment of Pulmonary Arterial Hypertension
  • Teplizumab-mzwv (Tzield) – Commercial only
  • Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
  • Tremelimumab (Imjudo)
  • Ublituximab-xiiy (Briumvi) – Commercial only


The following medical drug policies are new and specific for Medicaid Expansion:
Note: There may be corresponding policies for our Commercial lines of business or policies that apply to both Commercial and Medicaid Expansion lines of business.

  • Crizanlizumab-tmca (Adakveo)
  • Exagamglogene autotemcel (Casgevy)
  • Lovotibeglogene autotemcel (Lyfgenia)
  • Spesolimab (Spevigo)


The following medical drug policies are revised and specific for Medicaid Expansion:
Note: There may be corresponding policies for our Commercial lines of business or policies that apply to both Commercial and Medicaid Expansion lines of business.

  • Agalsidase beta (Fabrazyme) and Pegunigalsidase alfa-iwxj (Elfabrio)
  • Omalizumab (Xolair)


The following medical drug policies have a coding change effective July 1, 2024:

  • Medications and Diabetic Supplies Payable on the Pharmacy Benefit – Medicaid Expansion only


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

  • Alpha1-Proteinase Inhibitors
  • Autologous Cellular Immunotherapy for Prostate Cancer
  • Bezlotoxumab (Zinplava)
  • Burosumab (Crysvita) – Commercial only
  • Etranacogene dezaparvovec (Hemgenix) – Medicaid Expansion only
  • Lecanemab (Leqembi) – Medicaid Expansion only
  • Medication Therapy Management Services (MTMS) – Medicaid Expansion only
  • Mirvetuximab soravtansine-gynx (Elahere)
  • Mogamulizumab-kpkc (Poteligeo)
  • Mosunetuzumab-axgb (Lunsumio)
  • Nadofaragene firadenovec-vncg (Adstiladrin)
  • Naxitamab (Danyelza)
  • Olipudase alfa-rpcp (Xenpozyme) – Medicaid Expansion only
  • Plerixafor (Mozobil)
  • Tafasitamab-cxix (Monjuvi)
  • Tagraxofusp-erzs (Elzonris)
  • Teclistamab-cqyv (Tecvayli)
  • Teplizumab-mzwv (Tzield) – Medicaid Expansion only
  • Teprotumumab-trbw (Tepezza) – Medicaid Expansion only
  • Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors
  • Therapeutic Radiopharmaceuticals for Prostate Cancer
  • Tisotumab vedotin-tftv (Tivdak)
  • Trilaciclib (Cosela)


The following medical drug policy will be retired September 2024:

  • Aducanumab-avwa (Aduhelm) – Medicaid Expansion only
  • Moxetumomab Pasudotox-tdfk (Lumoxiti)