ND Committee Review
Internal Medical Policy Committee 11-23-2021 Adopted Medicaid Expansion specific policy Effective January 01, 2022
Internal Medical Policy Committee 5-24-2022 Changed second UC criteria to "The individual must have had a 30-day trial of a preferred agent or a TNF inhibitor, as evidenced by paid claims or pharmacy printouts." from "The individual must have had a 30-day trial of each preferred biologic agent, as evidenced by paid claims or pharmacy printouts." based on Version 2022.4 of the PDL
Internal Medical Policy Committee 5-23-2023 - Effective June 01, 2023
- Updated CD and UD criteria based on Version 2023.2 of the PDL
Internal Medical Policy Committee 1-16-2024 Effective January 01, 2024
- Removed subcutaneous formulation of ustekinumab (Stelara) as this is part of policy ME-I-9015-001
Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024
- Added new code, Q5138 for ustekinumab-auub (Wezlana) intravenous to the policy
- Updated policy title to remove "Stelara"
Internal Medical Policy Committee 11-19-2024 Effective December 01, 2024
- Updated criteria based on the DHHS PDL Version 2024.6
Internal Medical Policy Committee 11-19-2024 Effective January 01, 2025
- Added new code, Q9997, to the policy
Internal Medical Policy Committee 03-11-2025 Effective April 01, 2025
- Added new codes Q9998 and Q9999 to the policy
- Updated criteria based on the DHHS PDL Version 2025.3
Internal Medical Policy Committee 05-13-2025 Effective July 01, 2025
- Added new codes, Q5098, Q5099, and Q5100, to the policy
Internal Medical Policy Committee 07-08-2025 Effective August 01, 2025
- Updated criteria based on the DHHS PDL Version 2025.5