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 - Medical Pharmacy
Note: There may be corresponding policies for our Commercial lines of business.
The following Medicaid Expansion medical drug prior authorization policies are new and effective Dec. 1, 2026:
- Apitegromab-mstn (Isembyld)
- Atidarsagene autotemcel (Lenmeldy)
- Fecal Microbiota, live-jslm (Rebyota)
- Lunsotogene parvec-cwha (Otarmeni)
The following Medicaid Expansion prior authorization medical drug policies have coding changes effective Dec. 1, 2026:
- Intravitreal Injections
- Added new HCPCs code Ranluspec (J3490)
- Portable External Infusion Pump
- Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors
- Removed Iobenguane I 131 (A9590) and associated codes (77300, 78804, 96365, 96374) from policy
The following Medicaid Expansion prior authorization medical drug policies have revisions effective Nov. 1, 2026:
- Abatacept (Orencia) IV
- Updated clinical criteria based on the DHHS PDL Version 2026.6
- Updated diagnosis codes
- Ado-trastuzumab emtansine (Kadcyla)
- Criteria update to FDA compendia sources
- Cetuximab (Erbitux)
- Criteria update to FDA compendia sources
- Ipilimumab (Yervoy)
- Updated clinical criteria- FDA compendia
- Updated preferred products based on DHHS PDL Version 2026.7 - Avsola now non-preferred
- Updated diagnosis codes
- Panitumumab (Vectibix)
- Updated diagnosis codes - added D37.3
- Updated clinical criteria- FDA Compendia
- Pertuzumab (Perjeta)
- Criteria update to FDA compendia sources
- Pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo)
- Criteria update to FDA compendia sources
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Criteria update to FDA compendia sources for Tecentriq and Jemperli
- Therapeutic Radiopharmaceuticals for Prostate Cancer
- Criteria update to FDA compendia sources
The following Medicaid Expansion prior authorization medical drug policies have revisions effective Dec. 1, 2026:
- ADAMTS13, recombinant-krhn (Adzynma)
- Updated reauthorization criteria based on DHHS PDL Version 2026.6
- Afamitresgene autoleucel (Tecelra)
- Updated criteria for Tecelra - age 12 and older
- Anifrolumab-fnia (Saphnelo)
- Updated criteria based on the DHHS PDL Version 2026.7
- Autologous Cellular Immunotherapy for Prostate Cancer
- Criteria update to FDA compendia sources
- Belimumab (Benlysta)
- Updated clinical criteria based on the DHHS PDL Version 2026.7
- Updated systemic lupus erythematosus criteria
- Bendamustine
- Updated criteria-Added compendia sources
- Casimersen (Amondys-45)
- Updated clinical criteria based on the DHHS PDL Version 2026.6
- Certolizumab (Cimzia)
- Updated clinical criteria based on the DHHS PDL Version 2026.6
- Crovalimab (Piasky)
- Updated reauthorization criteria
- The individual must have experienced one of the clinical benefit metrics defined in the renewal criteria that was not met Ultomiris with Voydeya
- Desensitization Treatment for Heart and Renal Transplant
- Updated Renal Transplant criteria
- Defined ABO blood group incompatibility (isoagglutinin titer greater than 1:4)
- Edaravone (Radicava)
- Updated initial criteria based on the DHHS PDL Version 2026.6
- Added neuromuscular specialist to covered prescribers
- Updated reauthorization criteria based on the DHHS PDL Version 2026.6
- Further defined therapeutic response as a score decline of less than six (6) on the ALS Function Rating Scale-Revised (ALSFRS-R).
- Elosulfase alfa (Vimizim)
- Updated diagnosis codes- added E76.210
- Elotuzumab (Empliciti)
- Criteria update to FDA compendia sources
- Enfortumab vedotin-ejfv (Padcev)
- Updated clinical criteria based on the DHHS PDL Version 2026.6
- Eptinezumab-jjmr (Vyepti)
- Updated initial and renewal criteria based on the DHHS PDL Version 2026.6
- Eribulin Mesylate (Halaven)
- Criteria update to FDA compendia sources
- Evinacumab-dgnb (Evkeeza)
- Updated criteria (LDL-C levels) based on the DHHS PDL Version 2026.7
- Galsulfase (Naglazyme)
- Updated diagnosis codes-Added E76.3
- Golimumab (Simponi Aria, Immgolis Intri)
- Updated criteria based on the DHHS PDL Version 2026.7
- Updated rheumatoid arthritis criteria
- Gonadotropin Releasing Hormones (GnRHs) Analogs
- Updated clinical criteria for Supprelin LA for precocious puberty based on the DHHS PDL Version 2026.6
- Guselkumab (Tremfya)
- Updated criteria based on the DHHS PDL Version 2026.7
- Inclisiran (Leqvio)
- Updated criteria LDL-C levels) based on the DHHS PDL Version 2026.7
- Infliximab
- Criteria update to FDA compendia sources
- Injectable Collagenase Clostridium Histolyticum (Xiaflex)
- REMS statement for treatment of Peyronie's disease
- Criteria update to FDA compendia sources
- Intra-arterial Melphalan (Hepzato)
- Criteria update to FDA compendia sources
- Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee
- Updated clinical criteria for repeat treatment cycles
- Intravitreal Injections
- Added new HCPCs code Ranluspec (J3490)
- Updated criteria to include diagnosis of retinopathy of prematurity
- Updated preferred agents based on the DHHS PDL Version 2026.7
- Yesafili now preferred
- Lucentis now non-preferred
- Irinotecan Liposomal (Onivyde)
- Criteria update to FDA compendia sources
- Lumasiran (Oxlumo)
- Updated reauthorization criteria based on the DHHS PDL Version 2026.6
- "Decrease of 30% from baseline or normalization of urinary oxalate excretion"
- Mirikizumab-mrkz (Omvoh) IV
- Updated initial criteria for ulcerative colitis required based on the DHHS PDL Version 2026.7
- Motixafortide (Aphexda)
- Criteria update to FDA compendia sources
- Nadofaragene firadenovec-vncg (Adstiladrin)
- Criteria update to FDA compendia sources
- Narsoplimab-wuug (Yartemlea)
- Updated criteria based on DHHS PDL Version 2026.7
- Nogapendekin alfa inbakicept-pmln (Anktiva)
- Criteria update to FDA compendia sources
- Oncologic Indications for Histone Deacetylase (HDAC) Inhibitors
- Criteria update to FDA compendia sources
- Pegaspargase (Oncaspar), Asparaginase Erwinia Chrysanthemi (Rylaze), and Calaspargase Pegol-mknl (Asparlas)
- Updated policy name to remove discontinued product Erwinaze
- Pharmacologic Treatment of Pulmonary Arterial Hypertension
- Updated clinical criteria based on the DHHS PDL Version 2026
- Must be prescribed by, or in consult with a pulmonologist or cardiologist
- Updated reauthorization criteria
- Portable External Infusion Pump
- Added codes A4228, E0788 Vyafuser pump system to policy
- Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
- Updated non-preferred agents based on the DHHS PDL Version 2026.7
- Riabni and Truxima now non-preferred
- Updated clinical criteria- FDA compendia
- Secukinumab (Cosentyx) IV
- Updated criteria based on the DHHS PDL Version 2026.7
- Added indications ankylosing spondylitis, juvenile idiopathic arthritis, hidradenitis suppurativa and rheumatoid arthritis
- Updated psoriatic arthritis criteria
- Added diagnosis codes to reflect expanded indications
- Siltuximab (Sylvant)
- Criteria update to FDA compendia sources
- Teplizumab-mzwv (Tzield)
- Updated diagnosis codes- added E10.10, E10.11, E10.65
- Updated clinical criteria based on the DHHS PDL Version 2026.7
- Therapeutic Radiopharmaceuticals for Neuroendocrine Tumors
- Updated Lu-177 criteria to FDA compendia statement
- Added diagnosis codes C7B.03, C7B.05, C7B.06, C7B.07, C7B.08, C7B.8
- Removed Iobenguane I 131 (A9590) and associated codes (77300, 78804, 96365, 96374) from policy as product withdrawn from market by manufacturer
- Tildrakizumab-asmn (Ilumya)
- Updated criteria based on the DHHS PDL Version 2026.7
- Tofersen (Qalsody)
- Updated initial criteria based on the DHHS PDL Version 2026.6
- Added neuromuscular specialist to covered prescribers
- Updated reauthorization criteria based on the DHHS PDL Version 2026.6
- Further defined therapeutic response as a score decline of less than six (6) on the ALS Function Rating Scale-Revised (ALSFRS-R).
- Vedolizumab (Entyvio)
- Updated initial criteria for ulcerative colitis required based on the DHHS PDL Version 2026.7
- Viltolarsen (Viltepso)
- Updated clinical criteria based on the DHHS PDL Version 2026.6
- Voretigene Neparvovec-rzyl (Luxturna)
- Criteria update to FDA compendia sources
The following Medicaid Expansion medical drug policies were reviewed and have no changes:
- Chemodenervation with Botulinum Toxin
- Emapalumab-lzsg (Gamifant)
- Romiplostim (Nplate)
- Tebentafusp-tebn (Kimmtrak)
- Treatment of Hyperhidrosis
The following Medicaid Expansion medical drug policies will be retired effected Dec.1, 2026:
- Bezlotoxumab (Zinplava)
- Esketamine (Spravato)
- Fidanacogene elaparvovec (Beqvez)
Commercial Updates
The following Commercial prior authorization medical drug policies have changes effective Dec. 1, 2026:
- Portable External Infusion Pump
- Added codes A4228, E0788 Vyafuser pump system to policy
