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Pharmacy Policies Available Online

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:

Elivaldogene autotemcel (Skysona)
Etranacogene dezaparvovec-drlb (Hemgenix)
Hemophilia Products – Commercial only
Spesolimab (Spevigo)
Treatment of Congenital Athymia – Commercial only

The following medical drug policies are new 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.

  • Granulocyte Colony-Stimulating Factors – Medicaid Expansion only
  • Medication Therapy Management Services (MTMS) – Medicaid Expansion only 

The following medical drug policy was revised and pegfilgrastim products will require precertification effective January 1, 2023:

  • Granulocyte Colony-Stimulating Factors – Commercial only

The following medical drug policies were revised:

  • Abatacept (Orencia) IV – Commercial only
  • Alemtuzumab (Lemtrada) – Commercial only
  • Bevacizumab (Avastin) and Bevacizumab Biosimilars
  • Blinatumomab (Blincyto)
  • Certolizumab (Cimzia) – Commercial only
  • Chemodenervation with Botulinum Toxin
  • Enzyme Replacement Therapies – Commercial only
  • Fulvestrant (Faslodex)
  • Golimumab (Simponi Aria) – Commercial only
  • IL-1 and IL-1b Blockers – Commercial only
  • Infliximab
  • Inotuzumab ozogamicin (Besponsa)
  • Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee
  • Intravitreal Injections
  • Ixabepilone (Ixempra)
  • Lumasiran (Oxlumo) – Commercial only
  • Monoclonal Antibodies for the Treatment of Eosinophilic Conditions – Commercial only
  • Natalizumab (Tysabri) – Commercial only
  • Ocrelizumab (Ocrevus) – Commercial only
  • Omacetaxine mepesuccinate (Synribo)
  • Omalizumab (Xolair) – Commercial only
  • Panitumumab (Vectibix)
  • Pegcetacoplan (Empaveli) – Commercial only
  • Pralatrexate (Folotyn)
  • Risankizumab-rzaa (Skyrizi) IV – Commercial only
  • Romiplostim (Nplate)
  • Tildrakizumab-asmn (Ilumya)
  • Tocilizumab (Actemra) – Commercial only
  • Ustekinumab (Stelara) IV – Commercial only
  • Vedolizumab (Entyvio)
  • Ziv-aflibercept (Zaltrap)

The following medical drug policies have a coding change effective January 1, 2023:

  • Bevacizumab (Avastin) and Bevacizumab Biosimilars
  • Continuous Glucose Monitoring Systems – Commercial only
  • Fulvestrant (Faslodex)
  • Medications and Diabetic Supplies Payable on the Pharmacy Benefit – Medicaid Expansion only
  • Treatment of Hereditary Amyloidosis – Commercial only

The following medical drug policies were reviewed with no clinical content change:

  • Aducanumab-avwa (Aduhelm) – Commercial only
  • Cerliponase Alfa (Brineura) – Commercial only
  • Cetuximab (Erbitux)
  • Exondys 51 (eteplirsen) – Commercial only
  • Ibalizumab-uiyk (Trogarzo)
  • Ipilimumab (Yervoy)
  • Mogamulizumab-kpkc (Poteligeo)
  • Polymerized Sucralfate Malate Paste (ProThelial) – Commercial only

The following new retail pharmacy Utilization Management programs are effective January 1, 2023:

  • Camzyos Prior Authorization Quantity Limit Program
  • Vijoice Prior Authorization Quantity Limit Program – NetResults Formulary only
  • GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit Program Summary

The following medical drug policies will be retired December 31, 2022:

  • Melphalan Flufenamide (Pepaxto)
  • Necitumumab (Portrazza)

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
  • Aducanumab-avwa (Aduhelm)
  • Agalsidase beta (Fabrazyme)
  • Alemtuzumab (Lemtrada)
  • Burosumab (Crysvita)                                                                                 
  • Casimersen (Amondys-45)
  • Cerliponase Alfa (Brineura)
  • Edaravone (Radicava)
  • Elosulfase alfa (Vimizim)
  • Emapalumab-lzsg (Gamifant)
  • Eptinezumab-jjmr (Vyepti)
  • Evinacumab-dgnb (Evkeeza)
  • Exondys 51 (eteplirsen)
  • Galsulfase (Naglazyme)
  • Givosiran (Givlaari)
  • Golimumab (Simponi Aria)
  • Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
  • Idursulfase (Elaprase)
  • IL-1 and IL-1b Blockers
  • Inebilizumab-cdon (Uplizna)
  • Laronidase (Aldurazyme)
  • Lumasiran (Oxlumo)
  • Luspatercept (Reblozyl)
  • Natalizumab (Tysabri)
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Pegloticase (Krystexxa)
  • Portable External Infusion Pump
  • Sebelipase alfa (Kanuma)
  • Teprotumumab-trbw (Tepezza)
  • Treatment of Gaucher Disease
  • Treatment of Hereditary Amyloidosis
  • Vestronidase alfa-vjbk (Mepsevii)
  • Viltolarsen (Viltepso)
  • Voretigene Neparvovec-rzyl (Luxturna)
  • Viltolarsen (Viltepso)

Voretigene Neparvovec-rzyl (Luxturna)