Retail Pharmacy Medical Policy Change

Effective April 1, 2021, Blue Cross Blue Shield of North Dakota (BCBSND) is updating the retail pharmacy Multiple Sclerosis Agents Prior Authorization with Quantity Limit (MS PAQL) Program Summary criteria. Providers and members who are affected by the criteria changes will receive a letter from BCBSND. 

Key Points:

  • Patients new to Multiple Sclerosis (MS) treatment will need to try a generic product (dimethyl fumarate or glatiramer) prior to being eligible for a preferred brand product. Patients will need to try both a generic and preferred (formulary) brand product before being eligible for a non-preferred (non-formulary) brand product. A prior authorization request will need to be submitted for all MS treatments.
    • Patients with highly active diseases or patients who have tried and failed three (3) different drug classes can bypass these requirements through the prior authorization process.
  • Patients who are currently on brand name Tecfidera or Copaxone will need to switch to dimethyl fumarate or glatiramer, respectively. 
    • Patients who demonstrate intolerance or hypersensitivity to generic equivalents may continue brand name Tecfidera and Copaxone with new approval through the prior authorization process.
  • Providers with patients who might require different therapies based on disease characteristics and treatment history can use the prior authorization process to evaluate the appropriateness of using other MS agents before the cost-effective generics.

This program applies to all BCBSND lines of business. The criteria changes will be posted on April 1, 2021, and can be accessed through MyPrime.com or bcbsnd.com

For additional questions, call our Provider Contact Center at 1-800-368-2312.