Pharmacy Policies Available Online

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 policy is new effective April 2024:

  • ADAMTS13, recombinant-krhn (Adzynma)

The following medical drug policy is new effective May 2024:

  • Plasminogen, human-tvmh (Ryplazim) – Commercial only

The following medical drug policies were revised:

  • Anifrolumab-fnia (Saphnelo)
  • Belimumab (Benlysta) Bevacizumab (Avastin) and Bevacizumab Biosimilars
    • Added bevacizumab-tnjn (Avzivi)
  • Cetuximab (Erbitux)
  • Enzyme Replacement Therapies – Commercial only
    • Added criteria for cipaglucosidase alfa-atga (Pombiliti) and miglustat (Opfolda)
    • Added trial of agalsidase beta (Fabrazyme) to pegunigalsidase alfa-iwxj (Elfabrio) criteria
  • Eptinezumab-jjmr (Vyepti) – Commercial only
  • Granulocyte Colony-Stimulating Factors
  • Inclisiran (Leqvio) – Commercial only
  • Intravitreal Injections
  • Lecanemab (Leqembi) – Commercial only
    • Adopted medically necessary criteria
  • Nusinersen (Spinraza) – Commercial only
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
    • Added reauthorization criteria
  • Secukinumab (Cosentyx) IV – Commercial only
    • Added self-administered secukinumab (Cosentyx) agent criteria
  • Spesolimab (Spevigo) – Commercial only

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) & Pegunigalsidase alfa-iwxj (Elfabrio)
  • Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
  • Omalizumab (Xolair)

The following medical drug policies have a coding change effective Apr. 1, 2024:

  • Chemodenervation with Botulinum Toxin
  • Elranatamab-bcmm (Elrexfio)
  • Intra-arterial Melphalan (Hepzato)
  • Mirikizumab-mrkz (Omvoh) IV
  • Motixafortide (Aphexda)
  • Natalizumab
  • Pozelimab-bbfg (Veopoz)
  • Secukinumab (Cosentyx) IV
  • Talquetamab-tgvs (Talvey)
  • Tocilizumab – Commercial only

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

  • Ado-trastuzumab emtansine (Kadcyla)
  • Alglucosidase alfa (Lumizyme) and Avalglucosidase alfa-ngpt (Nexviazyme) – Medicaid Expansion only
  • Capsaicin patch (Qutenza) – Commercial only
  • Denosumab (Prolia, Xgeva) – Commercial only
  • Etranacogene dezaparvovec-drlb (Hemgenix) – Commercial only
  • Givosiran (Givlaari) – Commercial only
  • Ibalizumab-uiyk (Trogarzo)
  • Injectable Collagenase Clostridium Histolyticum (Xiaflex)
  • Isatuximab-irfc (Sarclisa)
  • Romosozumab-aqqg (Evenity)
  • Viltolarsen (Viltepso) – Commercial only
  • Voretigene Neparvovec-rzyl (Luxturna) – Commercial only
  • Vyondys 53 (Golodirsen)

The following are changes to the retail pharmacy Utilization Management programs:

  • Weight Loss Agents Prior Authorization with Quantity Limit
  • Effective Apr. 1, 2024 – Zepbound added as a target agent within the program