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Pharmacy Policies Available Online

Blue Cross Blue Shield of North Dakota·ND · Oncology, Hematology, Pharmacy +5 more·Pharmacy
Effective date
Nov 10, 2026
We identified it
Sep 12, 2026
Days to comply
56 days

Summary

BCBSND released comprehensive pharmacy policy updates effective November 10, 2026, affecting 15+ medications with changes to prior authorization criteria, billing codes (HCPCS additions/discontinuations), ICD-10 coding, and clinical guidelines alignment. Multiple HCPCS codes transition on October 1, 2026 (J3590 discontinued, new codes J3590 replacements and J9066 added). Billing teams must update systems for new biosimilar products (Ponlimsi, denosumab-adet, Omlyclo, Avyxa) and discontinued codes before the effective dates.

Action Required

Before Nov 10, 2026
By October 1, 2026: Billing team must update billing system to discontinue HCPCS code J3590 for Ponlimsi, denosumab-adet, Enoby/Xtrenbo, Osvyrti/Jubereq, Boncresa, and Oziltus. Add new HCPCS codes J1757 (effective 10/01/2026 for Avlayah), J9066 (effective 10/01/2026 for Avyxa bendamustine), and Q5173 (effective 10/01/2026 for Prolia biosimilars). Remove discontinued codes C9308 and J9999 from Kyxata billing. By November 10, 2026: Update prior authorization logic and clinical criteria in PA system for all 15+ affected medications (Avlayah, Bendamustine, Beovoumab, Bevacizumab Oncology, Cyramza, Denosumab, Elahere, Encelto, Halaven, Infliximab, Ixempra, Kyxata, Omalizumab, Paclitaxel Albumin-Bound, Pemetrexed, Pluvicto) to reflect NCCN guideline updates. Add new ICD-10 diagnosis codes (C83.36, C50.A0-C50.A2, D48.60-D48.62) to covered diagnosis tables. Update contractor information from National Government Services, Inc. to Wellpoint Federal in all systems and correspondence. Alert clinical staff and providers to new biosimilar products (Ponlimsi, denosumab-adet, Omlyclo, Avyxa) with parity status and steerage requirements. Update encounter forms and prior auth request templates to reflect simplified contraindication language (consolidated to 'member does not have FDA labeled contraindications'). Failure to implement code changes by October 1 will result in claim denials for new products and discontinued code rejections. Failure to update PA criteria by November 10 will cause inappropriate denials for compliant prescriptions.

Affected Billing Codes

J1757
J3590
J9033
J9066
Q5173
J9999
C9308
A52451
A52370
A52399
A52448
C83.36
C18.1
D48.60
D48.61
D48.62
C50.A0
C50.A1
C50.A2