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
Note: There may be corresponding policies for our Commercial lines of business.
The following Medicaid Expansion medical drug policies having coding updates effective Jan. 1, 2026:
- Bevacizumab (Avastin) and Bevacizumab Biosimilars
- Esketamine (Spravato)
- Implantable Hormone Replacement Pellets
- Nipocalimab-aahu (Imaavy)
- Telisotuzumab vedotin-tllv (Emrelis)
Commercial Updates
Medical Pharmacy
The following Commercial medical drug policies have coding updates effective Jan. 1, 2026:
New Code | Brand Name (Generic Name) |
J9282 | Zusduri (mitomycin) |
Q5160 | Jobevne (bevacizumab-nwgd) |
J9184 | Avgemsi (gemcitabine hydrochloride) |
J3389 | Zevaskyn (prademagene zamikeracel) |
J9256 | Imaavy (nipocalimab-aahu) |
J9326 | Emrelis (telisotuzumab vedotin-tllv) |
J3387 | Skysona (elivaldogene autotemcel) |
Deleted Code | Brand Name (Generic Name) |
J9019** | Erwinaze (asparaginase) |
J1572** | Flebogamma 5% DIF (immune globulin) |
J0172** | Aduhelm (aducanumab-avwa) |
J1562** | Vivaglobin (immune globulin 100 mg) |
** Discontinuation of existing Code due to drug no longer available
Retail Pharmacy
The following retail pharmacy UM programs have updates effective Feb. 1, 2026:
*see www.myprime.com/en/forms.html on or after Feb. 1, 2026
UM Program Name | Program Type | Formulary | Update |
Biologic Immuno-modulators | PAQL | Commercial, HIM, Net Results | *Clarified that conventional agent therapy requirements can be bypassed if patient has previously used a biologic Immunomodulator or a systemic targeted synthetic small molecule drug (excluding previous use of these agents with samples) *Rinvoq requests for ulcerative colitis and Crohn's disease now require failure of one of the following preferred agents: Entyvio, Skyrizi, Tremfya, Adalimumab-aaty, Adalimumab-adaz, Hadlima, Simlandi, Selarsdi, Steqeyma, Yesintek *Added requirement that for pediatric patients age 6 years or older requesting Tremfya for treatment of plaque psoriasis or psoriatic arthritis, patients must weigh at least 40 kg *Added requirement that pediatric patients requesting Simponi for the treatment of ulcerative colitis must weigh 15 kg or greater *For Xeljanz oral solution used for psoriatic arthritis, added requirement that there must be support for why the patient cannot use Xeljanz 5 mg tablets |
Hepatitis C Direct Acting Antivirals | PAQL | Commercial, HIM, Net Results | *Added in specialist requirement to create approval pathway for members not meeting AASLD simplified treatment regimen requirements. |
Zeposia | PAQL | Commercial, HIM, Net Results | *Clarified that conventional agent therapy requirements can be bypassed if patient has previously used a biologic Immunomodulator or a systemic targeted synthetic small molecule drug (excluding previous use of these agents with samples) *Rinvoq requests for ulcerative colitis and Crohn's disease now require failure of one of the following preferred agents: Entyvio, Skyrizi, Tremfya, Adalimumab-aaty, Adalimumab-adaz, Hadlima, Simlandi, Selarsdi, Steqeyma, Yesintek *Removed requirement that patients have an electrocardiogram within 6 months of starting therapy |
