Pharmacy Policies Available Online

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 pharmacy policies were reviewed by the Internal Medical Policy Committee on May 14, 2024, and will be updated within the next 30 days. These changes apply to both our Commercial and Medicaid Expansion Policies unless noted.

The following medical drug policies are new effective June 2024:

  • Atidarsagene autotemcel (Lenmeldy)
  • Fidanacogene elaparvovec (Beqvez)
  • Immune Globulin Therapy – ME specific policy
  • Lifileucel (Amtagvi)
  • Nogapendekin alfa inbakicept-pmln (Anktiva) (Commercial only)

The following medical drug policies were revised:

  • Amivantamab-vmjw (Rybrevant)
  • Chemodenervation with Botulinum Toxin
  • Contraceptive Management (Commercial only)
  • Enfortumab vedotin-ejfv (Padcev)
  • Givosiran (Givlaari) (Commercial only)
  • Intravitreal Injections (Commercial only)
  • Ipilimumab (Yervoy)
  • Irinotecan Liposomal (Onivyde)
  • Lumasiran (Oxlumo) (Commercial only)
  • Margetuximab-cmkb (Margenza)
  • Obinutuzumab (Gazyva)
  • Pharmacologic Treatment of Pulmonary Arterial Hypertension
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
    • Added tislelizumab-jsgr (Tevimbra) to the policy.
  • Ramucirumab (Cyramza)
  • Sutimlimab-jome (Enjaymo) (Commercial only)
  • Treatment of Hereditary Amyloidosis (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.

  • Eculizumab (Soliris) and Ravulizumab (Ultomiris)
  • Nusinersen (Spinraza)
  • Portable External Infusion Pump
    • Updated Omnipod criteria to "Omnipod insulin management systems may be covered through the pharmacy benefit."
  • Romosozumab-aqqg (Evenity)

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

  • ADAMTS13, recombinant-krhn (Adzynma)
  • Betibeglogene autotemcel (Zynteglo)
  • Granulocyte Colony Stimulating Factors
  • Lovotibeglogene autotemcel (Lyfgenia)
  • Medications and Diabetic Supplies Payable on the Pharmacy Benefit
  • Mirikizumab-mrkz (Omvoh) IV
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
  • Secukinumab (Cosentyx) IV
  • Ustekinumab (Stelara) IV

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

  • Copanlisib (Aliqopa)
  • Drug Indications
  • Elotuzumab (Empliciti)
  • Eribulin Mesylate (Halaven)
  • Esketamine (Spravato)
  • Evinacumab-dgnb (Evkeeza) (Commercial only)
  • Guselkumab (Tremfya) (Commercial only)
  • Inebilizumab-cdon (Uplizna) (Commercial only)
  • Intravenous Anesthetics for Off-Label Indications
  • Loncastuximab tesirine-lpyl (Zynlonta)
  • Pegaspargase (Oncaspar), Asparaginase Erwinia Chrysanthemi (Erwinaze, Rylaze), and Calaspargase Pegol-mknl (Asparlas)
  • Pegloticase (Krystexxa) (Commercial only)
  • Siltuximab (Sylvant)
  • Tildrakizumab-asmn (Ilumya) (Medicaid Expansion only)
  • Vuity (pilocarpine hydrochloride ophthalmic solution) (Commercial only)

The following medical drug policy will be retired July 2024:

Inhalation Products for the Management of Cystic Fibrosis