Pharmacy Policies Available Online

Blue Cross Blue Shield of North Dakota (BCBSND) regularly develops and revises medical policies in response to rapidly changing medical technology. Our commitment is to update the provider community as medical policies are adopted and/or revised. Benefit determinations are made based on the medical policy in effect at the time of service.

The following pharmacy policies were reviewed by the Internal Medical Policy Committee on Jan. 22, 2020. Please see policy for changes. Policies are available at www.bcbsnd.com/providers/policies-precertification.

The following medical drug policies are new and require precertification:

  • Certolizumab (Cimzia)
  • Crizanlizumab-tmca (Adakveo)
  • Eribulin Mesylate (Halaven)
  • Panitumumab (Vectibix)
  • Pralatrexate (Folotyn)
  • Siltuximab (Sylvant)

The following medical drug policies were revised and require precertification:

  • Alpha1-Proteinase Inhibitor Infusions
  • Prolastin-C, Aralast NP, Glassia, Zemaira
  • Belimumab (Benlysta)
  • Burosumab (Crysvita)
  • Daunorubicin and Cytarabine Liposomal (Vyxeos)
  • Eculizumab (Soliris) and Ravulizumab (Ultomiris)
  • Immune Globulin Therapy
  • Bivigam, Carimune NF, Cuvitru, Febogamma, Flebogamma DIF, Gammagard, Gammaked, Gammaplex, Gamunex-C, Hizentra, Hyqvia, Octagam, Panglobulin NF, Privigen
  • Injectable Collagenase Clostridium Histolyticum
  • Xiaflex
  • Ipilimumab (Yervoy)
  • Onasemnogene abeparvovec-xioi (Zolgensma)
  • Oncologic Indications for Histone deacetylase (HDAC) inhibitors
  • Beleodaq, Istodax
  • Pegaspargase (Oncaspar), Asparaginase Erwinia Chrysanthemi (Erwinaze), and Calaspargase Pegol-mknl (Asparlas)
  • Pegloticase (Krystexxa)
  • Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
  • Bavencio, Imfinzi, Keytruda, Libtayo, Opdivo, Tecentriq
  • Ramucirumab (Cyramza)
  • Tildrakizumab-asmn (Ilumya)
  • Vestronidase Alfa (Mepsevii)

The following medical drug policies are new:

  • Implantable Hormone Replacement Pellets
  • Therapeutic Radiopharmaceuticals in Oncology
  • Lutathera
  • Vyondys 53 (Golodirsen)

The following medical drug policies were revised:

  • Gonadotropin Releasing Hormones (GnRHs) Analogs
  • Eligard, Lupaneta, Lupron, Supprelin LA*, Trelstar, Triptodur*, Vantas*
  • Granulocyte Colony-Stimulating Factors
  • Fulphila, Granix, Leukine, Neulasta, Neupogen, Nivestym, Udenyca, Zarxio, Ziextenzo
  • Olaratumab (Lartruvo)
    *requires precertification

The following medical drug policies have coding updates effective 1/1/2020:

  • Brexanolone (Zulresso)
  • Polatuzumab vedotin-piiq (Polivy)*
    *requires precertification

The following medical drug policies were retired:

  • Bortezomib (Velcade)
  • Carboplatin (Paraplatin)
  • Docetaxel (Taxotere)
  • Gemcitabine (Gemzar, Infugem)
  • Levoleucovorin (Fusilev or Khapzory)
  • Pemetrexed (Alimta)
  • Radiation Treatment with Lutathera