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. All policies are applicable to Commercial and Medicaid Expansion unless otherwise noted.
The following medical drug policy is new:
- Tofersen (Qalsody) – Commercial only
The following medical drug policies were revised:
- Chemodenervation with Botulinum Toxin
- Continuous Glucose Monitoring Systems – Commercial only
- Drug Indications
- Enfortumab vedotin-ejfv (Padcev)
- Eribulin Mesylate (Halaven)
- Esketamine (Spravato)
- Evinacumab-dgnb (Evkeeza) – Commercial only
- Hemophilia Products – Commercial only
- Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
- Inebilizumab-cdon (Uplizna) – Commercial only
- Inhalation Products for the Management of Cystic Fibrosis
- Intravitreal Injections
- Ipilimumab (Yervoy)
- Irinotecan Liposomal (Onivyde)
- Loncastuximab tesirine-lpyl (Zynlonta)
- Obinutuzumab (Gazyva)
- Pegaspargase (Oncaspar), Asparaginase Erwinia Chrysanthemi (Erwinaze, Rylaze), and Calaspargase Pegol-mknl (Asparlas)
- Pegloticase (Krystexxa) – Commercial only
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Ramucirumab (Cyramza)
- Siltuximab (Sylvant)
- Sutimlimab-jome (Enjaymo) – Commercial only
- Tezepelumab-ekko (Tezspire) – Commercial only
The following medical drug policies were reviewed with no clinical content change:
- Copanlisib (Aliqopa)
- Elotuzumab (Empliciti)
- Intravenous Anesthetics for Off-Label Indications
- Margetuximab-cmkb (Margenza)
- Tagraxofusp-erzs (Elzonris)
The following retail pharmacy Utilization Management program is effective 6/1/2023:
- Relyvrio Prior Authorization with Quantity Limit
The following retail pharmacy Utilization Management programs are effective 7/1/2023:
- Furoscix Prior Authorization with Quantity Limit
- Tezspire Prior Authorization with Quantity Limit
The following Net Results Formulary retail pharmacy Utilization Management programs will be retired:
- Metformin ER Step Therapy Quantity Limit
- Oral Tetracycline Derivatives Prior Authorization
- Rayos Prior Authorization
The following medical drug policies are new and specific for Medicaid Expansion:
- Romosozumab-aqqg (Evenity) – ME only
- Tildrakizumab-asmn (Ilumya) – ME only
- Vedolizumab (Entyvio) – ME only
The following medical drug policy is revised and specific for Medicaid Expansion:
- Ustekinumab (Stelara) IV – ME only
The following medical drug policy is being retired effective June 30, 2023:
- Belantamab mafodotin (Blenrep)
Questions?
Contact our Commercial Provider Service Center at 1-800-368-2312 or Medicaid Expansion Provider Service Center at 1-833-777-5779 for additional information.
