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 policies were reviewed by the Internal Medical Policy Committee on Nov. 19, 2024.
Effective Dec. 9, 2024, Commercial medical drug policies will be transitioning to the Medical Pharmacy Solutions team at Prime Therapeutics. Medicaid Expansion medical drug policies will remain with BCSND.
Commercial Updates
The following Commercial medical drug policy was revised effective Dec. 1, 2024:
- Guselkumab (Tremfya)
Note: Several Commercial medical drug policies will be transitioning to the Medical Pharmacy Solutions team at Prime Therapeutics on Dec. 9, 2024. See www.gatewaypa.com/policydisplay/52 for the list of prior authorization and post service claim edit medical drug policies effective Dec. 9, 2024.
The following Commercial medical drug policies will be retired on Dec. 31, 2024:
- Aducanumab-avwa (Aduhelm)
- Afamitresgene autoleucel (Tecelra)*
- Donanemab (Kisunla)*
- Guselkumab (Tremfya)*
- Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
- Imetelstat (Rytelo)*
- Omidubicel as Adjunct Treatment for Hematologic Malignancies*
- Polymerized Sucralfate Malate Paste (ProThelial)
- Vuity (pilocarpine hydrochloride ophthalmic solution)
*See www.gatewaypa.com/policydisplay/52 on Jan. 1, 2025, for current policy
Medicaid Expansion Updates
The following Medicaid Expansion medical drug policies are new and effective Jan. 1, 2025:
Note: There may be corresponding policies for our Commercial lines of business.
- Crovalimab (Piasky)
- Guselkumab (Tremfya)
- Imetelstat (Rytelo)
- Nogapendekin alfa inbakicept-pmln (Anktiva)
- Tocilizumab
The following Medicaid Expansion medical drug policies are revised and effective Dec. 1, 2024:
Note: There may be corresponding policies for our Commercial lines of business.
- Abatacept (Orencia) IV
- Alemtuzumab (Lemtrada)
- Beremagene geperpavec-svdt (Vyjuvek)
- Edaravone (Radicava)
- Efgartigimod (Vyvgart) and Efgartigmod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
- Golimumab (Simponi Aria)
- Idursulfase (Elaprase)
- Lumasiran (Oxlumo)
- Mirikizumab-mrkz (Omvoh) IV
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Added Tecentriq Hybreza to the policy
- Risankizumab-rzaa (Skyrizi) IV
- Secukinumab (Cosentyx) IV
- Tofersen (Qalsody)
- Treatment of Hereditary Amyloidosis
- Ustekinumab IV
The following Medicaid Expansion medical drug policies have a coding change effective Jan. 1, 2025:
- Eculizumab and Ravulizumab
- Exagamglogene autotemcel (Casgevy)
- Fidanacogene elaparvovec (Beqvez)
- Granulocyte Colony-Stimulating Factors
- Immune Globulin Therapy
- Romiplostim (Nplate)
- Tarlatamab-dlle (Imdelltra)
- Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
- Ustekinumab IV
Note: A number of medical drug policies will have new policy numbers for Medicaid Expansion due to the transition of Commercial medical policies to the Medical Pharmacy Solutions team at Prime Therapeutics on Dec. 9, 2024.
The following Medicaid Expansion medical drug policies were reviewed with no clinical content change:
- Bezlotoxumab (Zinplava)
- Burosumab (Crysvita)
- Casimersen (Amondys-45)
- Cerliponase Alfa (Brineura)
- Elosulfase alfa (Vimizim)
- Emapalumab-lzsg (Gamifant)
- Evinacumab-dgnb (Evkeeza)
- Exondys 51 (eteplirsen)
- Galsulfase (Naglazyme)
- Givosiran (Givlaari)
- Inebilizumab-cdon (Uplizna)
- Laronidase (Aldurazyme)
- Luspatercept (Reblozyl)
- Ocrelizumab (Ocrevus)
- Sebelipase alfa (Kanuma)
- Treatment of Gaucher Disease
- Vestronidase Alfa-vjbk (Mepsevii)
- Viltolarsen (Viltepso)
- Voretigene Neparvovec-rzyl (Luxturna)
The following are new retail pharmacy Utilization Management programs:
- Fabhalta Prior Authorization with Quantity Limit
- Effective Jan. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
- Kerendia Prior Authorization with Quantity Limit
- Effective Jan. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
- Primary Biliary Cholangitis Prior Authorization with Quantity Limit
- Effective Jan. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
- Spevigo Prior Authorization with Quantity Limit
- Effective Dec. 1, 2024, for NetResults, Commercial and Health Insurance Marketplace Formularies
- Xolremdi Prior Authorization with Quantity Limit
- Effective Jan. 1, 2025, for NetResults, Commercial and Health Insurance Marketplace Formularies
