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.
Commercial Updates
Medical Pharmacy
The following Commercial prior authorization medical drug policies are new and effective April 1, 2026:
*see www.gatewaypa.com/policydisplay/52 on or after April 1, 2026
- Exdensur (depemokimab-ulaa)
- Hymovis One (viscoelastic hyaluronan)
- Lunsumio Velo (mosunetuzumab-axgb)
- Rybrevant Faspro (amivantamab and hyaluronidase-lpuj)
- Yartemlea (narsoplimab-wuug)
Retail Pharmacy
The following retail pharmacy Utilization Management (UM) programs are new effective April 1, 2026:
*see www.myprime.com/en/forms.html on or after April 1, 2026
- Brensocatib Prior Authorization Quantity Limit Program
- NetResults Formulary
- Harliku Prior Authorization Quantity Limit Program
- NetResults Formulary
- Leqembi Prior Authorization Quantity Limit Program
- Commercial and HIM Formularies
- Leucovorin Prior Authorization Quantity Limit Program
- NetResults Formulary
- Rhapsido Prior Authorization Quantity Limit Program
- NetResults, Commercial and HIM Formularies
- Vyjuvek Prior Authorization Quantity Limit Program
- NetResults, Commercial and HIM Formularies
The following retail pharmacy Utilization Management (UM) program is being retired effective April 1, 2026:
- Metformin ER Quantity Limit
- NetResults, Commercial and HIM Formularies
The following retail pharmacy Utilization Management (UM) programs have updates effective April 1, 2026:
*see www.myprime.com/en/forms.html on or after April 1, 2026
UM Program Name | Program Type | Formulary | Update for Provider Letter |
ADHD | QL | Commercial, HIM, NetResults | *removed Evekeo ODT (obsolete) and quantity limit update |
Afrezza | PAQL | Commercial, HIM, NetResults | *clinical criteria update and standardized wording and format of language |
Agamree, Emflaza (formerly Emflaza) | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Alternative Dosage Form | PAQL | NetResults | *removed Dartisla ODT (obsolete) and clinical criteria update |
Amifampridine | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Antidepressant | STQL | Commercial, HIM, NetResults | *removed Viibryd titration pack (obsolete), clinical criteria update and standardized wording and format of language |
Arikayce | PAQL | NetResults | *clinical criteria update |
Atopic Dermatitis | ST | Commercial, HIM, NetResults | *clinical criteria update |
Atypical Antipsychotics | STQL | Commercial, HIM, NetResults | *removed Vraylar titration pack(obsolete), clinical criteria update and standardized wording and format of language |
Atypical Antipsychotics-Extended Maintenance Agents | PA | Commercial | *clinical criteria update and standardized wording and format of language |
Biologic Immunomodulators | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Bonjesta/Diclegis | PAQL | NetResults | *clinical criteria update |
CFTR | PAQL | Commercial, HIM, NetResults | *renewal criteria update |
Cibinqo | PAQL | Commercial, HIM, NetResults | *clinical criteria update and initial approval length increased to 12 months |
Constipation Agents | PAQL | NetResults | *clinical criteria update |
Continuous Glucose Monitoring Systems | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Daybue | PAQL | NetResults | *clinical criteria update |
DPP-4 Inhibitors | PA/QL | Commercial, HIM, NetResults | *removed brand Oseni and brand Kazano (obsolete), clinical criteria update and standardized wording and format of language |
Duvyzat | PAQL | Commercial, HIM, NetResults | *standardized wording and format of language |
Efgartigimod | PAQL | Commercial, HIM, NetResults | *clinical criteria and quantity limit updates |
Factor VIII and von Willebrand Factor | PAQL | Commercial, HIM, NetResults | *removed Stimate nasal spray (obsolete) |
Gabapentin ER | STQL | Commercial, HIM, NetResults | *clinical criteria update |
GLP-1 Agonists | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Glucose Test Strips | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Growth Hormone | PA | Commercial, HIM, NetResults | *clinical criteria update |
HAE | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Hereditary Angioedema | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Hetlioz | PAQL | Commercial, HIM, NetResults | *no changes during annual review |
HSDD | PAQL | NetResults | *clinical criteria update |
IL-13 Antagonist | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
IL-31 Inhibitor | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
IL-4 Inhibitor | PAQL | Commercial, HIM, NetResults | *clinical criteria and quantity limit updates |
IL-5 Inhibitors | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Insomnia | STQL | Commercial, HIM, NetResults | *clinical criteria update |
Insulin Combination Agents | QL | Commercial, HIM, NetResults | *no changes during annual review |
Interstitial Lung Disease (ILD) | PAQL | Commercial, HIM, NetResults | *adding Jascayd and clinical criteria update |
Journavx | QL | NetResults | *clinical criteria update |
Kerendia | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Ketorolac | QL | Commercial, HIM, NetResults | *no changes during annual review |
Korlym | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Long-Acting Insulin | PAQL | Commercial, HIM, NetResults | *clinical criteria and quantity limit updates |
Lyrica and Savella | STQL | Commercial, HIM, NetResults | *clinical criteria update |
Multiple Sclerosis Agents | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Myalept | PA | Commercial, HIM, NetResults | *clinical criteria update |
Northera | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Ophthalmic Antihistamine | ST | NetResults | *clinical criteria update |
Opioids ER | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Opioids IR | QL | Commercial, HIM, NetResults | *removed an oxycodone-APAP agent (obsolete) |
Oral Inhalers | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Otezla | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Oxybate | PAQL | Commercial, HIM, NetResults | *clinical criteria update and standardized wording and format of language |
PAH (formerly Oral PAH) | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Pain Medication Combination Agents | QL | Commercial, HIM, NetResults | *clinical criteria update |
Pancreatic Enzymes | PA | Commercial, HIM | *clinical criteria update |
Parathyroid Hormone For Osteoporosis | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
PCSK9 Inhibitors | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Phosphate Binders | STQL | HIM, NetResults | *clinical criteria update |
PPI | STQL | Commercial, HIM, NetResults | *clinical criteria update |
Procysbi | PA | Commercial, HIM, NetResults | *clinical criteria update |
Progesterones | STQL | NetResults | *clinical criteria update |
Pseudobulbar Affect | PAQL | NetResults | *clinical criteria update |
Rapid to Intermediate Acting Insulin | PAQL | Commercial, HIM, NetResults | *clinical criteria and quantity limit updates |
Retinoids PA | PA | Commercial, HIM, NetResults | *clinical criteria update |
Retinoids ST | STQL | Commercial, HIM | *clinical criteria update |
Rezurock | PAQL | Commercial, HIM, NetResults | *standardized wording and format of language |
Risdiplam | PAQL | Commercial, HIM, NetResults | *standardized wording and format of language |
SA Oncology | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Sensipar | PA | Commercial, HIM, NetResults | *clinical criteria update |
SGLT2 Inhibitors | PA/QL | Commercial, HIM, NetResults | *clinical criteria update and standardized wording and format of language |
SSIA Agents | PAQL | NetResults | *no changes during annual review |
Statin | ST | Commercial | *clinical criteria update |
Substrate Reduction Therapy | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Sunosi | PAQL | Commercial, HIM, NetResults | *standardized wording and format of language |
Tezspire | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Thrombopoietin Receptor Agonist, Tavalisse and Wayrilz | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Topical Antibiotics | ST | Commercial | *clinical criteria update |
Topical Antifungals, itraconazole, terbinafine | PAQL | NetResults | *clinical criteria update |
Topical Doxepin | PAQL | NetResults | *clinical criteria update |
Topical Lidocaine | PAQL | NetResults | *clinical criteria update |
Topical NSAID | STQL | Commercial, HIM, NetResults | *clinical criteria update |
Topiramate ER | PAQL | NetResults | *clinical criteria update |
Transmucosal Immediate Release Fentanyl (TIRF) | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Triptans | STQL | Commercial, HIM, NetResults | *clinical criteria update |
Urea Cycle Disorders | PA | NetResults | *clinical criteria update |
Urinary Incontinence Agents | ST/QL | Commercial, NetResults | *clinical criteria update |
Vascepa | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
VMAT2 Inhibitors | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
Vykat XR | PAQL | Commercial, HIM, NetResults | *added an operations note |
Wakix | PAQL | Commercial, HIM, NetResults | *standardized wording and format of language |
Weight Management | PAQL | Commercial, HIM, NetResults | *clinical criteria and quantity limit criteria updates |
Xhance | PAQL | NetResults | *clinical criteria update and standardized wording and format of language |
Xolair | PA | Commercial, HIM, NetResults | *clinical criteria update |
Zelsuvmi | PAQL | Commercial, HIM, NetResults | *clinical criteria update |
The following retail pharmacy administrative actions will occur April 1, 2026:
UM Program Name | Program Type | Formulary | Summary of Changes |
Alternative Dosage Form | PAQL | NetResults | Addition of furosemide 10mg/ml oral solution, Javadin, and desloratadine as targets |
Atypical Antipsychotics | STQL | Commercial, HIM, NetResults | Addition of Vraylar 0.5 mg and 0.75 mg capsule |
Biologic Immunomodulators | PAQL | Commercial, HIM, NetResults | Addition of Adalimumab-bwwd |
Daybue | PAQL | NetResults | Addition of Daybue Stix |
SA Oncology | PAQL | Commercial, HIM, NetResults | Addition of Xpovio 80mg pack |
