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 Dec. 1, 2023:
- Mirikizumab-mrkz (Omvoh) – Commercial only
- Secukinumab (Cosentyx) IV – Commercial only
The following medical drug policies are new effective Jan. 1, 2024:
- Elranatamab-bcmm (Elrexfio)
- Intra-arterial Melphalan (Hepzato)
- Omidubicel as Adjunct Treatment for Hematologic Malignancies – Commercial only
- Pozelimab-bbfg (Veopoz)
- Talquetamab-tgvs (Talvey)
The following medical drug policies are new & specific for Medicaid Expansion effective Oct. 1, 2023:
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.
- Tofersen (Qalsody)
The following medical drug policies are new & 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.
- Bezlotoxumab (Zinplava)
The following medical drug policies were revised:
- Abatacept (Orencia) IV – Commercial only
- Updated age criteria for PJIA and PsA
- Certolizumab (Cimzia) – Commercial only
- Chemodenervation with Botulinum Toxin
- Added daxibotulinumtoxinA-lanm (Daxxify)
- Crizanlizumab-tmca (Adakveo)
- Golimumab (Simponi Aria) – Commercial only
- Human Growth Hormone – Commercial only
- Added Omnitrope as a preferred product
- IL-1 and IL-1b Blockers – Commercial only
- Updated HIDS, MKD and TRAPS criteria
- Intravitreal Injections
- Added aflibercept (Eylea HD)
- Added avacincaptad pegol (Izervay)
- Luspatercept (Reblozyl) – Commercial only
- Added criteria for Anemia Without Previous Erythropoiesis Stimulating Agent Use
- Panitumumab (Vectibix)
- Pegcetacoplan (Empaveli) – Commercial only
- Updated initial criteria including other FDA approved indication and age criteria
- Risankizumab-rzaa (Skyrizi) IV – Commercial only
- Romiplostim (Nplate)
- Rozanolixizumab-noli (Rystiggo) – Commercial only
- Removed trial products for individuals with positive serological test for anti-AChR antibodies
- Tezepelumab-ekko (Tezspire) – Commercial only
- Added to the initial and reauthorization criteria a trial of self-administered tezepelumab-ekko (Tezspire) product (i.e., Tezspire prefilled pen) or information that self-administration is not appropriate for the individual
- Removed from the initial criteria, Xolair and Dupixent trial criteria
- Tildrakizumab-asmn (Ilumya)
- Tocilizumab (Actemra) – Commercial only
- Added biosimilar tocilizumab-bavi (Tofidence)
- Removed Systemic Juvenile Idiopathic Arthritis (SJIA) specific criteria
- Treatment of Congenital Athymia – Commercial only
- Ustekinumab (Stelara) IV – Commercial only
- Vedolizumab (Entyvio) – Commercial only
- Added “the intravenous formulation may be covered under the medical benefit; please refer to pharmacy policies for coverage of the subcutaneous formulation.”
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.
- Abatacept (Orencia) IV
- Eculizumab (Soliris) and Ravulizumab (Ultomiris)
- Efgartigimod (Vyvgart) and Efgartigmod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
- Added efgartigmod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
- Evinacumab-dgnb (Evkeeza)
- Galsulfase (Naglazyme)
- Golimumab (Simponi Aria)
- Natalizumab (Tysabri)
- Rozanolixizumab-noli (Rystiggo)
The following medical drug policies have a coding change effective Jan. 1, 2024:
- Beremagene geperpavec-svdt (Vyjuvek)
- Delandistrogene moxeparvovec (Elevidys) – Commercial only
- Efgartigimod (Vyvgart) and Efgartigmod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo) – Medicaid Expansion only
- Efgartigmod alfa-fcab (Vyvgart) and Efgartigmod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo) – Commercial only
- Enzyme Replacement Therapies – Commercial only
- Epcoritamab-bysp (Epkinly)
- Glofitamab-gxbm (Columvi)
- Tofersen (Qalsody) – Medicaid Expansion only
- Tofersen (Qalsody) – Commercial only
- Valoctocogene Roxaparvovec-rvox (Roctavian)
The following medical drug policies were reviewed with no clinical content change:
- Aducanumab-avwa (Aduhelm) – Commercial only
- Agalsidase beta (Fabrazyme) – Medicaid Expansion only
- Alemtuzumab (Lemtrada) – Medicaid Expansion only
- Blinatumomab (Blincyto)
- Burosumab (Crysvita) – Medicaid Expansion only
- Casimersen (Amondys-45) – Medicaid Expansion only
- Cerliponase Alfa (Brineura) – Medicaid Expansion only
- Elivaldogene autotemcel (Skysona)
- Elosulfase alfa (Vimizim) – Medicaid Expansion only
- Emapalumab-lzsg (Gamifant) – Medicaid Expansion only
- Eteplirsen (Exondys 51) – Commercial only
- Exondys 51 (eteplirsen) – Medicaid Expansion only
- Fulvestrant (Faslodex)
- Givosiran (Givlaari) – Medicaid Expansion only
- Idursulfase (Elaprase) – Medicaid Expansion only
- IL-1 and IL-1b Blockers – Medicaid Expansion only
- Inebilizumab-cdon (Uplizna) – Medicaid Expansion only
- Inotuzumab ozogamicin (Besponsa)
- Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee
- Laronidase (Aldurazyme) – Medicaid Expansion only
- Lumasiran (Oxlumo) – Medicaid Expansion only
- Lumasiran (Oxlumo) – Commercial only
- Luspatercept (Reblozyl) – Medicaid Expansion only
- Medications and Diabetic Supplies Payable on the Pharmacy Benefit – Medicaid Expansion only
- Nusinersen (Spinraza) – Medicaid Expansion only
- Ocrelizumab (Ocrevus) – Medicaid Expansion only
- Omacetaxine mepesuccinate (Synribo)
- NOTE: Teva has notified the U.S. Food and Drug Administration (FDA) that SYNRIBO will be permanently discontinued upon exhaustion of the current inventory, expected in the fourth quarter of 2023.
- Pharmacologic Treatment of Pulmonary Arterial Hypertension
- Polymerized Sucralfate Malate Paste (ProThelial) – Commercial only
- Pralatrexate (Folotyn)
- Risankizumab-rzaa (Skyrizi) IV – Medicaid Expansion only
- Sebelipase alfa (Kanuma) – Medicaid Expansion only
- Treatment of Gaucher Disease – Medicaid Expansion only
- Treatment of Hereditary Amyloidosis – Medicaid Expansion only
- Treatment of Hereditary Amyloidosis – Commercial only
- Vestronidase Alfa-vjbk (Mepsevii) – Medicaid Expansion only
- Viltolarsen (Viltepso) – Medicaid Expansion only
- Voretigene Neparvovec-rzyl (Luxturna) – Medicaid Expansion only
- Ziv-aflibercept (Zaltrap)
The following are changes to the retail pharmacy Utilization Management programs:
- Oral Inhalers Prior Authorization – New
- Effective Jan. 1, 2024 – Commercial Formulary
- Growth Hormone Prior Authorization – Update
- Addition of Omnitrope as a preferred short-acting agent
- Effective Dec. 1, 2023 – All Formularies
- Joenja Prior Authorization with Quantity Limit – New
- Effective Nov. 1, 2023 – NetResults Formulary
- Pancreatic Enzyme Prior Authorization – New
- Effective Jan. 1, 2024 – Commercial and HIM/QHP Formularies
- Vowst Prior Authorization with Quantity Limit – New
- Effective Jan. 1, 2024 – NetResults Formulary
