CommercialPrior AuthHigh impact
Pharmacy Policies Updates
Blue Cross Blue Shield of North Dakota·ND·Pharmacy
Effective date
Apr 1, 2026
We identified it
Jun 19, 2026
Summary
BCBS North Dakota is implementing extensive pharmacy policy updates effective April 1, 2026, including new prior authorization requirements for 5 medical drugs (including Exdensur, Hymovis One, Lunsumio Velo, Rybrevant Faspro, and Yartemlea) and 6 new retail pharmacy utilization management programs. Additionally, over 80 existing pharmacy programs are being updated with revised clinical criteria, quantity limits, and coverage requirements.
Action Required
By March 31, 2026: Billing team must update prior authorization workflows for new medical pharmacy drugs (Exdensur, Hymovis One, Lunsumio Velo, Rybrevant Faspro, Yartemlea) and retail pharmacy programs (Brensocatib, Harliku, Leqembi, Leucovorin, Rhapsido, Vyjuvek). Review updated clinical criteria for over 80 existing pharmacy programs at www.gatewaypa.com/policydisplay/52 and www.myprime.com/en/forms.html. Remove Metformin ER quantity limit requirements from workflows. Update pharmacy prior authorization forms and billing system rules to reflect new criteria and quantity limits. Failure to obtain required prior authorizations will result in pharmacy claim denials.