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.

Medicaid Expansion Updates - Medical Pharmacy 
Note: There may be corresponding policies for our Commercial lines of business.

The following Medicaid Expansion medical drug prior authorization policies are new and effective Oct. 1, 2026:

  • Etelcalcetide (Parsabiv) 
  • Fosfomycin IV (Contepo) 
  • Narsoplimab-wuug (Yartemlea) 
  • Pivekimab Sunirine-pvzy (Decnupaz) 
  • Testosterone Androgens (AVEED and AZMIRO) 
  • Treatment of Hereditary Angioedema (HAE)
    • Ecallantide (Kalbitor®), C-1 esterase inhibitor [human] (Berinert®) and C1 esterase inhibitor [recombinant] (Ruconest®) 

The following Medicaid Expansion prior authorization medical drug policies have coding changes effective Oct. 1, 2026:

  • Golimumab (Simponi Aria, Immgolis Intri)
    • Added biosimilar Immgolis Intri (J3590) and updated policy name 
  • Granulocyte Colony-Stimulating Factors
    • Updated HCPCs code Filkri (Q5172) (10/1 new code) from J3590 
  • Idursulfase (Elaprase) and tividenofusp alfa-eknm (Avlayah)
    • Added HCPCs code J1757 (Avlayah) and updated policy name 
  • IL-1 and IL-1b Blockers   
    • Removed J2793 
  • Infliximab
    • Add ZYMFENTRA (infliximab-dyyb) (J1748) 
  • Medications and Diabetic Supplies Payable on the Pharmacy Benefit 
  • Removed codes J0135, J0596, J0597, J1290, Q5137 
  • Added codes: J0139, Q5106, J0801, J0802, J1941, J1809, J0605, J2502, J2354, J0885, J0901, J2793 
  • Octreotide acetate (Sandostatin LAR) and Lanreotide (Somatuline Depot)
    • Added HCPCs code J1932 (lanreotide depot) 
  • Pegzilarginase-nbln (Loargys)
    • Updated HCPCs code (new 10/1) to J1818 from J3590, C9399 
  • Teprotumumab-trbw (Tepezza) and Veligrotug-vvze (Lumvoa)
    • Updated policy name and added new agent Lumvoa (J3590) to policy 
  • Trabectedin (Yondelis, Evdi)
    • Updated policy name and criteria to include new manufacturer of trabectedin (Evdi) (J3590, J9999) 
    • Updated HCPCs codes Yondelis now J9362 (10/1 new code) from J9352 

The following Medicaid Expansion prior authorization medical drug policies have revisions effective Oct. 1, 2026:

  • Alpha1-Proteinase Inhibitors
    • Updated GVHD criteria to include need for specialist consultation 
    • Updated reauthorization criteria 
    • Updated societal positions to reflect GOLD 2026 guidelines 
  • Anifrolumab-fnia (Saphnelo)
    • Updated diagnosis codes: added M32.0, M32.14 
  • Axatilimab-csfr (Niktimvo)
    • Updated criteria based on the DHHS PDL Version 2026.5 
  • Beremagene geperpavec-svdt (Vyjuvek)
    • Added notation- typically outpatient covered under pharmacy benefit 
  • Bevacizumab (Avastin) and Bevacizumab Biosimilars
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Datopotamab deruxtecan-dlnk (Datroway)
    • Updated diagnosis codes- added C50.A0, C50.A1, C50.A2 
    • Updated breast cancer criteria 
  • Donanemab (Kisunla)
    • Added diagnosis code G30.9 
  • Eculizumab and Ravulizumab (Ultomiris)
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Exagamglogene autotemcel (Casgevy)
    • Updated criteria for sickle cell disease based on the DHHS PDL Version 2026.5 
  • Fam-trastuzumab Deruxtecan-nxki (Enhertu)
    • Updated Breast Cancer Criteria 
  • Granulocyte Colony-Stimulating Factors
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Guselkumab (Tremfya)
    • Updated criteria based on the DHHS PDL Version 2026.4 
    • Crohn's: added criteria for tobacco cessation counseling 
    • UC: added criteria must be prescribed by gastroenterologist 
  • Idursulfase (Elaprase) and tividenofusp alfa-eknm (Avlayah)
    • Updated criteria based on the DHHS PDL Version 2026.5 
  • IL-1 and IL-1b Blockers    
  • Updated gout flare criteria based on DHHS PDL Version 2026.4: Must have had 3 flares in previous year 
  • Updated diagnosis codes 
  • Infliximab
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
    • Added diagnosis code M05.A 
  • Intravitreal Injections
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Lifileucel (Amtagvi)
    • Updated clinical criteria
    • Added diagnosis code C43.10 
  • Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
    • Added indication to Fasenra - Hypereosinophilic syndrome 
    • Updated clinical criteria for Nucala for Eosinophilic asthma based on DHHS PDL version 2026.5 
    • Updated Diagnosis codes for J0517 (added D72.110, D72.119) 
  • Naxitamab (Danyelza)
    • Updated diagnosis-added C79.51, C79.52 
  • Octreotide acetate (Sandostatin LAR) and Lanreotide (Somatuline Depot)
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Omalizumab (Xolair)
    • Updated criteria for Chronic Idiopathic Urticaria and Eosinophilic Asthma based on DHHS PDL Version 2026.4           
    • CIU: updated criteria to a failed 60-day trial of second-gen h1 antihistamine 
    • Asthma: updated criteria to add smoking cessation counseling, removed step-through of LAMA 
    • Added diagnosis codes: Z91.0111, Z91.0112, Z91.0121, Z91.0122 
  • Portable External Infusion Pump
    • Updated criteria for replacement insulin pump "the requested pump must be compatible with a ND Medicaid preferred CGM" 
  • Pozelimab-bbfg (Veopoz)
    • Updated clinical criteria to require meningococcal vaccination 
  • Prademagene zamikeracel (Zevaskyn)
    • Updated criteria based on the DHHS PDL Version 2026.4 
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
    • Updated criteria for Bladder Cancer for Imfinzi 
    • Updated criteria for Breast cancer and Renal Cell Carcinoma for Keytruda and Keytruda Qlex 
  • Risankizumab-rzaa (Skyrizi) IV
    • Updated criteria based on the DHHS PDL Version 2026.6 
  • Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Romosozumab-aqqg (Evenity)
    • Removed criteria based on the DHHS PDL Version 2026.4 
  • Sacituzumab govitecan-hziy (Trodelvy)
    • Updated criteria for breast cancer 
  • Teplizumab-mzwv (Tzield)
    • Updated criteria based on the DHHS PDL Version 2026.5 
  • Tocilizumab
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Ustekinumab IV
    • Updated non-preferred agent criteria based on the DHHS PDL Version 2026.5 
  • Vedolizumab (Entyvio) 
    • Updated initial criteria required based on the DHHS PDL Version 2026.5 
    • Added tobacco cessation counseling requirement for treatment of Crohn's 
    • Added diagnosis codes: D89.810, D89.812, D89.813, K20.8, K20.81, K20.90, K20.91, K29.00, K29.01, K29.80, K29.81, K52.1 
  • Zenocutuzumab-zbco (Bizengri) 
    • Updated Criteria to include indication for cholangiocarcinoma 
    • Updated diagnosis codes: added C22.1, C24.0, C24.8, C24.9

The following Medicaid Expansion medical drug policies were reviewed and have no changes:

  • Capsaicin patch (Qutenza) 
  • Continuation of Drug Therapy 
  • Drug Indications 
  • Plasminogen, human-tvmh (Ryplazim) 
  • Revakinagene taroretcel-lwey (Encelto) 
  • Sutimlimab-jome (Enjaymo) 
  • Tafasitamab-cxix (Monjuvi) 

Commercial Updates 
The following Commercial medical drug policies were reviewed and have no changes:

  • Continuation of Drug Therapy 
  • Drug Indications 
  • Portable External Infusion Pump