Blue Cross Blue Shield of North Dakota (BCBSND) regularly 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 policies are new effective Sunday, Oct. 1, 2023:
- Epcoritamab-bysp (Epkinly)
- Glofitamab-gxbm (Columvi)
- Rozanolixizumab-noli (Rystiggo) – Commercial only
The following medical drug policies are new and specific for Medicaid Expansion effective Friday, Sept. 1, 2023:
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.
- Romiplostim (Nplate)
- Rozanolixizumab-noli (Rystiggo)
The following medical drug policies were revised:
- Alemtuzumab (Lemtrada) – Commercial only
- Added Glatopa as a preferred generic agent
- Brentuximab Vedotin (Adcetris)
- Daratumumab (Darzalex) and Daratumumab and Hyaluronidase-fihj (Darzalex Faspro)
- Eculizumab (Soliris) and Ravulizumab (Ultomiris) – Commercial only
- Emicizumab-kxwh (Hemlibra) – Commercial only
- Enzyme Replacement Therapies – Commercial only
- Added precertification drug pegunigalsidase alfa-iwxj (Elfabrio) to the policy effective Sunday, Oct. 1, 2023
- Fam-trastuzumab Deruxtecan-nxki (Enhertu)
- Hemophilia Products – Commercial only
- Updated NSAIDs criteria where applicable
- Intravitreal Implants
- Changed experimental/investigational statement throughout the policy to not medically necessary
- Intravitreal Injections
- Updated diagnosis code list for J0178, J0179, J2777, J2778, Q5128 and J2781
- Ixabepilone (Ixempra)
- Monoclonal Antibodies for the Treatment of Eosinophilic Conditions – Commercial only
- Updated CRSwNP initial criteria
- Natalizumab (Tysabri) – Commercial only
- Added Glatopa as a preferred generic agent for MS
- Added Skyrizi and adalimumab biosimilars to preferred CD agents list
- Ocrelizumab (Ocrevus) – Commercial only
- Added Glatopa as a preferred generic agent
- Omalizumab (Xolair) – Commercial only
- Updated CRSwNP initial criteria
- Polatuzumab vedotin-piiq (Polivy)
- Sacituzumab govitecan-hziy (Trodelvy)
- Teprotumumab-trbw (Tepezza) – Commercial only
- Ublituximab-xiiy (Briumvi) – Commercial only
- Added Glatopa as a preferred generic agent
The following medical drug policies have a coding change effective Sunday, Oct. 1, 2023:
- Hemophilia Products – Commercial only
- Intravitreal Injections
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Repository Corticotropin Intramuscular Injection
- Tofersen (Qalsody)
The following medical drug policies were reviewed with no clinical content change:
- Amivantamab-vmjw (Rybrevant)
- Betibeglogene autotemcel (Zynteglo)
- Brexanolone (Zulresso)
- Casimersen (Amondys-45) – Commercial only
- Chimeric Antigen Receptor Therapy for Multiple Myeloma
- Continuation of Drug Therapy
- Contraceptive Management – Commercial only
- Crizanlizumab-tmca (Adakveo)
- Pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo)
- Pharmacologic Treatment of Pulmonary Arterial Hypertension
- Plasminogen, human-tvmh (Ryplazim) – Medicaid Expansion only
- Portable External Infusion Pump – Commercial only
- Tebentafusp-tebn (Kimmtrak)
- Trabectedin (Yondelis)
- Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
- Treatment of Gaucher Disease – Commercial only
The following retail pharmacy Utilization Management programs are being retired Sunday, Oct. 1, 2023:
- Fibrates ST – Commercial and HIM Formularies
- Nocturia PAQL – NetResults Formulary 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.
- Capsaicin patch (Qutenza)
- Eculizumab (Soliris) and Ravulizumab (Ultomiris)
- Efgartigimod (Vyvgart)
- Eptinezumab-jjmr (Vyepti)
- Inclisiran (Leqvio)
- Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
- Omalizumab (Xolair)
- Sutimlimab-jome (Enjaymo)
- Tezepelumab-ekko (Tezspire)
Questions?
If you have additional questions regarding pharmacy policy changes, please contact the appropriate Provider Service Center.
- BCBSND 1-800-368-2312
- Medicaid Expansion 1-833-777-5779
