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.
Pharmacy Policies
New Policies
New Medicaid Expansion Policies
Revised Policies
Revised Medicaid Expansion Policies
Archived Policies
Coding Changes
Reviewed Policies
Retail Pharmacy Utilization Management Program Updates
The following medical drug policies are new effective March 2024:
- Exagamglogene autotemcel (Casgevy)
- Lovotibeglogene autotemcel (Lyfgenia)
- Motixafortide (Aphexda)
The following medical drug policies are new and specific for Medicaid Expansion effective Jan. 1, 2024:
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.
- Mirikizumab-mrkz (Omvoh) IV
The following medical drug policies are new and specific for Medicaid Expansion effective Mar. 1, 2024:
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.
- Secukinumab (Cosentyx) IV
- Velmanase alfa-tycv (Lamzede)
The following medical drug policies were revised:
- Beremagene geperpavec-svdt (Vyjuvek)
- Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
- Enzyme Replacement Therapies – Commercial only
- Added cipaglucosidase alfa-atga (Pombiliti) as always experimental/investigational
- Added velmanase alfa-tycv (Lamzede) as a precertification drug
- Gonadotropin Releasing Hormones (GnRHs) Analogs
- Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies – Commercial only
- Added Note: All products under J1729 became inactive as of Nov. 29, 2023
- Added diagnosis codes for J1729 for any supply that is being depleted
- Immune Globulin Therapy
- Added new IVIG, Alyglo, to the policy
- Implantable Hormone Replacement Pellets
- Intravitreal Injections
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Added toripalimab-tpzi (Loqtorzi)
- Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
- Combined rituximab (Rituxan) and rituximab biosimilar criteria
- Valoctocogene Roxaparvovec-rvox (Roctavian)
- Policy number changing as of Mar. 1, 2024
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)
- Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
- Added Note: All products under J1729 became inactive as of Nov. 29, 2023
- Added diagnosis codes for J1729 for any supply that is being depleted
- Infliximab – Medicaid Expansion only
- Adopting Medicaid Expansion specific policy effective Mar. 1, 2024
- Medications and Diabetic Supplies Payable on the Pharmacy Benefit
- Added codes, Q5131 and Q5132, to the policy
- Ustekinumab (Stelara) IV
- Removed subcutaneous formulation of ustekinumab (Stelara) as this is part of policy ME-I-9015-001
- Vedolizumab (Entyvio)
The following medical drug policy will be archived March 2024:
- Belatacept (Nulojix)
The following medical drug policies have a coding change effective Jan, 1, 2024:
- Rozanolixizumab-noli (Rystiggo) – Commercial only
- Rozanolixizumab-noli (Rystiggo) – Medicaid Expansion only
The following medical drug policies were reviewed with no clinical content change:
- Cerliponase Alfa (Brineura) – Commercial only
- Edaravone (Radicava) – Medicaid Expansion only
- Emapalumab-lzsg (Gamifant) – Commercial only
- Immune Prophylaxis for Respiratory Syncytial Virus (RSV) – Commercial only
- Infliximab – Commercial only
- Lurbinectedin (Zepzelca)
- Onasemnogene abeparvovec-xioi (Zolgensma) – Commercial only
- Oncologic Indications for Histone Deacetylase (HDAC) Inhibitors
- Portable External Infusion Pump – Medicaid Expansion only
- Treatment of Hereditary Angioedema (HAE) – Commercial only
The following are changes to the retail pharmacy Utilization Management programs:
- Miebo Prior Authorization with Quantity Limit – New
- Effective Apr. 1, 2024 – NetResults Formulary
