Blue Cross Blue Shield of North Dakota (BCBSND) regularly 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 November 2024:
- Afamitresgene autoleucel (Tecelra) – Commercial only
- Donanemab (Kisunla) – Commercial only
The following medical drug policies were revised:
- Chimeric Antigen Receptor Therapy for Multiple Myeloma
- Eculizumab (Soliris) and Ravulizumab (Ultomiris) – Commercial only
- Added criteria for indication Neuromyelitis Optica Spectrum Disorder (NMOSD) for Ultomiris
- Emicizumab-kxwh (Hemlibra) – Commercial only
- Hemophilia Products – Commercial only
- Luspatercept (Reblozyl) – Commercial only
- Omalizumab (Xolair) – Commercial only
- Added criteria for IgE-mediated food allergy indication
- Pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo)
- Polatuzumab vedotin-piiq (Polivy)
- Portable External Infusion Pump – Commercial only
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Risankizumab-rzaa (Skyrizi) IV – Commercial only
- Added criteria for ulcerative colitis indication
- Tocilizumab – Commercial only
- Added tocilizumab-aazg (Tyenne) to the policy
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.
- Eptinezumab-jjmr (Vyepti)
- IL-1 and IL-1b Blockers
- Medications and Diabetic Supplies Payable on the Pharmacy Benefit
- Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
- Risankizumab-rzaa (Skyrizi) IV
- Added criteria for ulcerative colitis indication
- Romiplostim (Nplate)
- Tezepelumab-ekko (Tezspire)
The following medical drug policies have a coding change effective October 1, 2024:
- Denosumab – Commercial only
- Fidanacogene elaparvovec (Beqvez)
- Nogapendekin alfa inbakicept-pmln (Anktiva) – Commercial only
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Tarlatamab-dlle (Imdelltra)
The following medical drug policies were reviewed with no clinical content change:
- Brentuximab Vedotin (Adcetris)
- Brexanolone (Zulresso)
- Capsaicin patch (Qutenza) – ME only
- Casimersen (Amondys-45) – Commercial only
- Continuation of Drug Therapy
- Daratumumab (Darzalex) and Daratumumab and Hyaluronidase-fihj (Darzalex Faspro)
- Inclisiran (Leqvio) – ME only
- Intravitreal Implants
- Ixabepilone (Ixempra)
- Monoclonal Antibodies for the Treatment of Eosinophilic Conditions – Commercial only
- Pegloticase (Krystexxa) – ME only
- Plasminogen, human-tvmh (Ryplazim) – ME only
- Repository Corticotropin Intramuscular Injection – Commercial only
- Sacituzumab govitecan-hziy (Trodelvy)
- Sutimlimab-jome (Enjaymo) – ME only
- Tebentafusp-tebn (Kimmtrak)
- Teprotumumab-trbw (Tepezza) – Commercial only
- Trabectedin (Yondelis)
- Treatment of Gaucher DiseaseAlpha1-Proteinase Inhibitors – Commercial only
The following medical drug policy will be retired:
- Copanlisib (Aliqopa) – Retiring November 2024
- Intravenous Anesthetics for Off-Label Indications – Retiring October 2024
The following are new retail pharmacy Utilization Management programs effective October 1, 2024, for the NetResults Formulary:
- Alternative Dosage Form Prior Authorization with Quantity Limit
- Filsuvez Prior Authorization
- Verkazia Prior Authorization with Quantity Limit
- Xhance Prior Authorization with Quantity Limit
