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 medical policies were reviewed by the Internal Medical Policy Committee on July 22, 2020. Please see policy for changes. Medical policies are available at www.bcbsnd.com/web/providers/policies.
The following medical drug policies are new and require precertification:
The following medical drug policies were revised and require precertification:
- Copanlisib (Aliqopa)
- Inotuzumab ozogamicin (Besponsa)
- Mogamulizumab-kpkc (Poteligeo)
- Trabectedin (Yondelis)
The following medical drug policies were revised:
- Certolizumab (Cimzia)
- Chemodenervation with Botulinum Toxin
- Continuous Glucose Monitoring Systems
- Contraceptive Management
- Daratumumab (Darzalex™)
- Daunorubicin and Cytarabine Liposomal (Vyxeos)
- Diabetic Services and Supplies
- Elosulfase alfa (Vimizim)
- Fulvestrant (Faslodex)
- Galsulfase (Naglazyme)
- Gonadotropin Releasing Hormones (GnRHs) Analogs
- Immune Globulin Therapy
- Injectable Collagenase Clostridium Histolyticum
- Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
- Moxetumomab Pasudotox-tdfk (Lumoxiti)
- Natalizumab (Tysabri)
- Omalizumab (Xolair)
- Oncologic Indications for Histone Deacetylase (HDAC) Inhibitors
- Portable External Infusion Pump
- Tocilizumab (Actemra)
- Ziv-aflibercept (Zaltrap)
The following medical drug policies were reviewed with no clinical content change:
- Belatacept (Nulojix)
- Cerliponase Alfa (Brineura)
- Esketamine (Spravato)
- Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
- Implantable Hormone Replacement Pellets
- Irinotecan Liposomal (Onivyde)
The following medical drug policy was retired:
The following medical drug policies had coding changes effective 7/1/2020:
- Crizanlizumab-tmca (Adakveo)
- Enfortumab vedotin-ejfv (Padcev)
- Eptinezumab-jjmr (Vyepti)
- Fam-trastuzumab Deruxtecan-nxki (Enhertu)
- Givosiran (Givlaari)
- Granulocyte Colony-Stimulating Factors
- Infliximab
- Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee
- Luspatercept (Reblozyl)
- Onasemnogene abeparvovec-xioi (Zolgensma)
- Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
- Teprotumumab-trbw (Tepezza)
- Vyondys 53 (Golodirsen)