CommercialPrior AuthHigh impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota·ND · Oncology, Rheumatology, Allergy & Immunology +3 more·Pharmacy
Effective date
Sep 9, 2026
We identified it
Jul 15, 2026
Summary
BCBSND released comprehensive pharmacy policy updates effective September 9, 2026, affecting 20+ medications across oncology, immunology, rheumatology, and other specialties. Changes include new FDA-approved indications (e.g., Datroway for triple-negative breast cancer, Fasenra for HES, Imfinzi for bladder cancer), revised prior authorization criteria, updated ICD-10 diagnosis codes, new biosimilar products, and administrative restructuring of authorization durations. Billing teams must update systems to reflect new covered diagnoses, dosing parameters, and clinical criteria before the effective date.
Action Required
By September 9, 2026: (1) Billing team must update clinical criteria and prior authorization logic in billing system for all 20+ affected medications; (2) Pharmacy and clinical staff must add newly approved indications and corresponding ICD-10 codes to authorization templates (e.g., triple-negative breast cancer for Datroway, HES for Fasenra, NMIBC for Imfinzi, ERBB2 mutations for Imfinzi/Imjudo/Libtayo); (3) Verify prior trial/failure requirements have been removed where specified (e.g., bisphosphonate trial requirements for Prolia/Evenity in very high-risk members); (4) Update dosing tables and maximum units calculations in system; (5) Remove outdated diagnosis codes (e.g., Mantle Cell Lymphoma codes C83.10-C83.18 from Levoleucovorin; Systemic Mastocytosis from Xgeva); (6) Add new product information (e.g., Immgolis INTRI biosimilar for Golimumab IV, Evenity glass PFS with automatic needle guard); (7) Update exacerbation definition criteria for IL-5 inhibitors (Cinqair, Exdensur, Fasenra, Nucala) to align with Prime Therapeutics class policy; (8) Verify contraindication language has been updated from specific to general FDA-based language across affected policies. Failure to implement changes will result in claim denials and delayed authorizations for newly covered indications.