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Blue Cross Blue Shield of North DakotaMedicaid · Prior Auth · Pharmacy · ND · Oncology, HematologyHigh impact

Pharmacy Policies Updates

Act
by Oct 1, 2025
Effective date
Oct 1, 2025
Identified
Jun 19, 2026

Summary

Blue Cross Blue Shield of North Dakota has updated multiple pharmacy prior authorization policies for specialty medications, with new requirements effective October 1, 2025 for Datopotamab deruxtecan-dlnk (Datroway) and revised policies for various oncology drugs effective November 1, 2025. These changes affect prior authorization criteria, step therapy requirements, and billing codes for high-cost specialty medications.

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What to do

by Oct 1, 2025 · 4 steps
01Billing team must update prior authorization requirements for Datopotamab deruxtecan-dlnk (Datroway) in billing system for Medicaid Expansion patients.
02By November 1, 2025: Update prior authorization policies for Bevacizumab, Exagamglogene autotemcel, Inebilizumab-cdon, Naxitamab, PD-1/PD-L1 blocking antibodies, and Tafasitamab-cxix.
03Review gateway portal at www.gatewaypa.com/policydisplay/52 for complete Commercial policy updates.
04Update billing codes and ICD-10 mappings in system.
If missed: Failure to obtain required prior authorizations will result in claim denials.

Codes mentioned

J9196C83.398C91.60C91.62Z94.84C86.10C86.20C86.50C88.00C88.40C72.30C72.31C72.32C37D15.0D38.4Z85.238C79.89D38.5D38.6C86.00C86.60Z85.3

Original notice

Pharmacy Policies Updates
bcbsnd.com · Always check the source before changing claims.
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Related changes

See all Blue Cross Blue Shield of North Dakota changes →
Pharmacy Policy UpdatesMediumEffective Feb 10, 2026 · PharmacyPharmacy Policies Available OnlineMediumEffective Mar 17, 2026 · PharmacyPharmacy Policy UpdatesHighNo effective date · PharmacyPharmacy Policy UpdatesMediumEffective Jun 10, 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 changesOncologyHematologyCode J9196Code C83.398Code C91.60Code C91.62Code Z94.84Code C86.10Code C86.20Code C86.50Code C88.00Code C88.40Code C72.30Code C72.31Code C72.32Code C37Code D15.0Code D38.4Code Z85.238Code C79.89Code D38.5Code D38.6Code C86.00Code C86.60Code Z85.3

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