CommercialPrior AuthHigh impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota·ND · Oncology, Hematology, Allergy & Immunology +2 more·Pharmacy
Effective date
Oct 13, 2026
We identified it
Aug 29, 2026
Summary
BCBSND has updated multiple commercial pharmacy prior authorization policies effective October 13, 2026, affecting 14 specialty drugs across oncology, immunology, and rare disease indications. Changes include expanded age eligibility for Casevy (sickle cell/thalassemia), relaxed LDL thresholds for Evkeeza, new FDA-approved indications for Keytruda IV/SQ, updated HCPCS billing codes, and revised clinical criteria to align with latest NCCN guidelines and FDA approvals. Billing teams must verify prior authorization requirements and update documentation for affected drug therapies before the October 13, 2026 effective date.
Action Required
By October 13, 2026: (1) Billing team must update prior authorization system rules for all 14 affected drugs (Adcetris, Amvuttra, Casevy, Cosela, Darzalex IV, Erbitux, Evkeeza, IVIG, Keytruda IV, Keytruda SQ, and others) to reflect new clinical criteria, age eligibility expansions, and FDA-approved indications. (2) Update diagnosis code mappings in billing software to include new ICD-10 codes for Langerhans Cell Histiocytosis (C96.0, C96.5, C96.6, C96.9, C96.Z, C96.20, C96.29) and CAR T-Cell toxicities (G92.00-G92.04, Z29.89). (3) Verify HCPCS code updates in claims submission system (note: HCPCS updates for some products effective 01/01/2027). (4) For Keytruda IV urothelial carcinoma cases, remove 'cisplatin-ineligibility' requirement from prior auth criteria—now covers both cisplatin-eligible and cisplatin-ineligible patients. (5) For Casevy, update system to approve patients age 2+ years (previously 12+ years) with documentation of ≥12 kg weight for sickle cell disease and transfusion-dependent thalassemia. (6) For Evkeeza HoFH, lower untreated LDL threshold from >500 mg/dL to >400 mg/dL and add LDLRAP1/ARH alleles as acceptable genetic testing results. (7) Providers must submit updated prior authorizations reflecting new indications (e.g., Keytruda + sacituzumab govitecan for triple-negative breast cancer; Keytruda adjuvant with belzutifan for RCC). Failure to update criteria will result in claim denials for otherwise covered indications.