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Pharmacy Policies Available Online
Effective date
Not stated in the notice
Identified
Aug 29, 2026
Summary
Blue Cross Blue Shield of North Dakota revised its Commercial prior authorization medical drug policies with changes effective October 13, 2026, including expanded indications for Casgevy, Keytruda, Opdivo and other products and updated criteria for many others. Effective September 1, 2026, Navitrux was added to the fosaprepitant policy and Cligavyx was added to the fulvestrant policy, each kept at full parity with its reference product, and the cerebral palsy spasticity exclusion was removed from the Xeomin pediatric upper limb indication. Several products also have HCPCS code changes effective January 1, 2027.
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What to do
Action · 15 steps
01Already effective October 13, 2026: For the Commercial prior authorization medical drug policies in this update, use the revised criteria when requesting prior authorization.
02For Casgevy, sickle cell disease patients must weigh at least 12 kg prior to the start of mobilization, and the indication now covers sickle cell disease with recurrent vaso-occlusive crises and transfusion dependent thalassemia in members at least 2 years of age.
03For Keytruda and Padcev, the requirement to be ineligible for cisplatin-containing chemotherapy was removed for muscle-invasive bladder cancer patients who are candidates for cystectomy, and the length of authorization and dosing sections were updated to show different neoadjuvant and adjuvant dosing for cisplatin-eligible and cisplatin-ineligible patients.
04For Leqembi IV, the dosing now aligns with the SQ policy, and the HCPCS description for J0174 now reads Lecanemab-irmb, for intravenous injection, 1 mg.
05For Evkeeza, LDLRAP1 and ARH are allowable alleles for DNA testing, and confirmation of untreated LDL is allowed when untreated LDL is above 400 mg/dL.
06For Leqvio, use is allowed for any member with treated LDL-C of 100 or more, or 70 or more with subclinical atherosclerosis or additional ASCVD risk factors.
07Length of authorization sections now list the number of days allowed for authorization durations for several products.
08By January 1, 2027: Update billing codes for the immune globulin products in this update.
09J1583 is effective January 1, 2027 for Gammaked and Gamunex-C, and J1586 is effective January 1, 2027 for Gammagard Liquid and Gammagard Liquid ERC.
10J1561 is discontinued for Gammaked and Gamunex-C on January 1, 2027, and J1569 is discontinued for Gammagard Liquid and Gammagard Liquid ERC on January 1, 2027.
11HCPCS codes for all products except Qivigy and Yimmugo are updated, effective 01/01/2027 for those two products.
12Already effective September 1, 2026: For the Commercial post service claim edit drug policies, Navitrux is kept at full parity with the reference product Emend, and the Dosing Limits section includes Navitrux.
13Cligavyx is kept at full parity with the reference product Faslodex, and the Dosing Limits section includes Cligavyx.
14For Xeomin, the indication heading is now Upper Limb Spasticity because the cerebral palsy exclusion was removed for patients 2 to 17 years of age.
15Check current applicability at the source link before acting on these past dates.
Codes mentioned
J0174J1561J1569J1583J1586C96.0C96.5C96.6C96.9C96.ZC96.20C96.29Z29.89C79.31C79.32C73C17.0C17.1C17.2C17.3C17.8C17.9Z85.068Z85.840Z85.850D37.3T80.82XAT80.82XST80.89XAT80.89XS
Original notice
Pharmacy Policies Available Online
bcbsnd.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of North Dakota changes →Pharmacy Policy UpdatesMediumEffective May 12, 2026 · PharmacyPharmacy Policy UpdatesMediumEffective Jun 10, 2026 · PharmacyPharmacy Policy UpdatesHighEffective Jul 14, 2026 · PharmacyPharmacy Policy UpdatesMediumEffective Aug 11, 2026 · PharmacyBrowse every Blue Cross Blue Shield of North Dakota change in the policy list
Related policy hubs
Blue Cross Blue Shield of North Dakota policiesND policy changesOncologyHematologyAllergy & ImmunologyCardiologyEndocrinologyNeurologyPharmacyPediatricsRheumatologyGeneticsInfectious DiseaseUrologyNeurosurgeryCode J0174Code J1561Code J1569Code J1583Code J1586Code C96.0Code C96.5Code C96.6Code C96.9Code C96.ZCode C96.20Code C96.29Code Z29.89Code C79.31Code C79.32Code C73Code C17.0Code C17.1Code C17.2Code C17.3Code C17.8Code C17.9Code Z85.068Code Z85.840Code Z85.850Code D37.3Code T80.82XACode T80.82XSCode T80.89XACode T80.89XS