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.
Medical Pharmacy
The following Commercial prior authorization medical drug policies are new and effective Oct. 1, 2026:
*see www.gatewaypa.com/policydisplay/52 on or after Oct. 1, 2026.
- Evdi (trabectedin)
- Filkri (filgrastim-laha)
- Immgolis Intri (goliumumab-sldi)
- Lumvoa (veligrotug-vvze)
- Otarmeni (lunsotogene parvec-cwha)
- Revtorpyk (gedatolisib)
- Sarclisa Escena (isatuximab-irfc)
- Tregzi (allogenic regulatory T-cell immunotherapy with HSPC and T cells-vldq)
- Wainua PFS (eplontersen sodium)
- Waskyra (etuvetidigene automecel)
The following Commercial prior authorization medical drug policies have updates effective Oct. 1, 2026:
*see www.gatewaypa.com/policydisplay/52 on or after Oct. 1, 2026
- Ustekinumab
Retail Pharmacy
The following retail pharmacy Utilization Management (UM) programs are new and effective Oct. 1, 2026:
*see www.myprime.com/en/forms.html on or after Oct. 1, 2026
- Leqembi IQLIK
- NetResults
- Vascepa
- NetResults
- Voyxact
- Commercial and HIM Formularies
The following retail pharmacy UM programs have updates effective Oct. 1, 2026:
*see www.myprime.com/en/forms.html on or after Oct. 1, 2026
UM Program Name | Program Type | Formulary | Update for Provider Letter |
Accrufer | PAQL | NetResults | *No changes on annual review |
ADHD/ADD Agents | QL | Commercial, HIM, NetResults | *Adding target agent Atoncy |
Alhemo | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Alinia | QL | NetResults | *Update to criteria wording and organization |
Alternative Dosage Form | PAQL | NetResults | *Adding target agents Quiofic and Granisol |
Anti-COVID19 | QL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
Antidepressant | STQL | Commercial, HIM, NetResults | *Program being retired |
Anti-Influenza | QL | NetResults | *No changes on annual review |
Antiretroviral | QL | NetResults | *No changes on annual review |
Atypical Antipsychotics | STQL | NetResults | *Addition of new target agent Bysanti to ST and QL |
Bempedoic Acid | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Biologic Immunomodulators | PAQL | Commercial, HIM, NetResults | *Removal of obsolete Humira Pediatric Crohn's starter kits *Addition of Avtozma as preferred product |
Bonjesta, Diclegis | PAQL | NetResults | *Approval length changed to 6 months. |
Cardiac Myosin Inhibitors | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Calcitonin Gene-Related Peptide (CGRP) | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Cholestasis Pruritus | PAQL | NetResults | *Adding target agent Lynavoy *Update to clinical criteria |
Cibinqo | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
CMV (cytomegalovirus) Oral | QL | NetResults | *No changes on annual review |
Coagulation Factor VIIa | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Constipation Agents | PAQL | NetResults | *Clinical criteria update |
Ctexli | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
DPP-4 Inhibitors | PAQL | Commercial, HIM, NetResults | *Removal of obsolete PA target agents: Kombiglyze XR and Nesina *Added the following generic agents as PA target agents: saxagliptin-metformin ER, alogliiptin, alogliptin-metformin, alogliptin-pioglitazone, sitagliptin oral solution, linagliptin-metformin, linagliptin-metformin ER, saxagliptin, sitagliptin (free base), sitagliptin (free base)-metformin, sitagliptin (free base)-metformin ER, and linagliptin *Addition of brand name Januvia and Janumet as PA target agents *Clinical criteria update |
Dry Eye Disease | PAQL | NetResults | *Clinical criteria update *Approval length for all targets except Eysuvis increased to 12 months |
Efgartigimod | PAQL | NetResults | *Clinical criteria update |
Elmiron | PAQL | NetResults | *Clinical criteria update |
Endari | PA | Commercial, HIM, NetResults | *Clinical criteria update |
Eohilia | PAQL | NetResults | *Update to criteria wording and organization |
Factor VIII and vWF | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Familial Chylomicronemia Syndrome | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Filspari | PAQL | Commercial, HIM, NetResults | *Increased quantity limit of 400 mg Filspari tablets to 2 per day *Clinical criteria update |
Gattex | PA | NetResults | *Clinical criteria update |
GLP-1 Agonists | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Glucose Test Strips and Meters | PAQL | Commercial | *Quantity limit criteria update |
Gonadotropin Hormones | PAQL | NetResults | *Update to criteria wording and organization |
Hemlibra | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Hemophilia Factor IX | PAQL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
Hepatitis C Direct Acting Antivirals | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Hetlioz | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Hympavzi | PAQL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
HCN Channel Blocker | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Imcivree | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
IL-13 | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
IL-31 | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
IL-4 | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
IL-5 | PAQL | Commercial, HIM, NetResults | *Clinical criteria update |
Leucovorin | PAQL | NetResults | *Increase in quantity limit for all target agents *Clinical criteria update |
Long-Acting Insulin | PAQL | Commercial, HIM, NetResults | *Added Civica-brand insulin glargine-yfgn as a target in the PA program *Quantity limit criteria update |
Lupus | PAQL | Commercial, HIM, NetResults | *Addition of Saphnelo pre-filled syringe and pen as PA targets *Clinical criteria update |
Multiple Sclerosis | PAQL | Commercial, HIM, NetResults | *Clinical criteria update *Quantity limit criteria update |
Neurotrophic Keratitis | PAQL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
Ophthalmic Antihistamine | STQL | NetResults | *Program being retired |
Ophthalmic Prostaglandins | QL | Commercial, HIM, NetResults | *Addition of new ST target agent: Zolymbus |
Oral Anticoagulant | QL | Commercial, HIM, NetResults | *Updated the quantity limit for the Xarelto starter pack to 51 tabs/180 days *Updated the quantity limit for Xarelto 15 mg tablets to 42 tablets per 30 days. *Quantity limit criteria updated |
Otezla | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Parathyroid Hormone Analog for Osteoporosis | PAQL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
PCSK9 Inhibitors | PAQL | Commercial, HIM, NetResults | *Addition of new PA target agent: Lerochol *Clinical criteria updated |
Phosphate Binders | ST/QL | ST:HIM QL: Commercial, HIM, NetResults | *Removed Renagel as a ST target as no longer available as brand (generic still a target in the quantity limit program) *Clinical criteria updated |
Primary Biliary Cholangitis | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Proton Pump Inhibitors (PPIs) | ST/QL | ST: Commercial, NetResults QL: Commercial, HIM, NetResults | *No changes on annual review |
Qfitlia | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Rapid to Intermediate Acting Insulin | PAQL | Commercial, HIM | *Update to quantity limit criteria |
Rhapsido | PAQL | Commercial, HIM, NetResults | *Update to quantity limit criteria |
Rho Kinase Inhibitor | QL | NetResults | *No changes on annual review |
Self Administered Oncology | PAQL | Commercial, HIM, NetResults | *Addition of new target agents, Veppanu and Cavhanza |
SGLT2 Inhibitors | PA/QL | PA: Commercial, HIM QL: NetResults | *Brand name Farxiga added as a PA target agent *Updated clinical criteria |
Statin | ST | Commercial | *Removed obsolete agent, Roszet as a ST target agent |
Subcutaneous Furosemide | PAQL | Commercial, HIM, NetResults | *No changes on annual review |
Tarpeyo | PAQL | Commercial, HIM, NetResults | *Update to criteria wording and organization |
Urinary Incontinence Agents | ST/QL | ST: Commercial QL: NetResults | *Removed Ditropan XL as a ST target as no longer available as brand (generic still a target in the quantity limit program) |
Vanrafia | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Vascepa | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Verkazia | PAQL | NetResults | *No changes on annual review |
Verquvo | PAQL | NetResults | *No changes on annual review |
VMAT2 Inhibitors | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Vowst | PAQL | NetResults | *Clinical criteria updated |
Voxzogo | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Weight Management | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Xolair | PA | Commercial, HIM, NetResults | *Clinical criteria updated |
Xolremdi | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
Zeposia | PAQL | Commercial, HIM, NetResults | *Clinical criteria updated |
