CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Medicaid Expansion Restricted Use Drug Precertification List

Defines drugs subject to precertification (prior authorization) and limited dispensing under the Medicaid Expansion program for Blue Cross Blue Shield - North Dakota; applies to providers and pharmacy/medical benefit processing for covered members.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyMedicaid Expansion Restricted Use Drug Precertification List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification (prior approval) for any drug listed on the Restricted Use/Precertification list before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+Listed restricted/medically administered drugs and biologics

~150+HCPCS/J and supply codes referenced

MultipleIncludes J-/Q- HCPCS and A-codes for supplies

1-833-777-5779language assistance phone number

Pg 6/14Document pagination (partial extract)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

General Precertification Criteria

Covered when precertification is obtained and benefit routing is determined according to the Preferred Drug List (PDL) and supported indications.

General precertification criteria: Drug is listed on the Restricted Use/Precertification list AND precertification (prior authorization) approved

Also requires FDA or compendia-supported indication for medications not explicitly on the list; consult the Preferred Drug List to determine benefit routing (pharmacy POS vs medical benefit).

Medications that are administered by the patient or another non‑professional and do not require professional administration are generally treated as self‑administered. These products are typically processed through the pharmacy benefit at point‑of‑sale per Department of Human Services Preferred Drug List guidance rather than billed to the medical benefit. Providers should consult the Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit and the PDL to determine correct benefit routing and any precertification requirements.

Items that are self‑administered and do not require a healthcare professional to give the drug are not typically covered under the medical benefit. Examples include continuous glucose monitor supplies coded with A4238, A4239, and A9276, which are processed through pharmacy point‑of‑sale systems per DHS Preferred Drug List. Verify coverage and routing on the PDL and the referenced Medical Policy before submitting medical claims.

Medications administered by an individual that do not require professional administration are considered self‑administered and therefore are generally excluded from the medical benefit. Such items should be billed and adjudicated through the pharmacy benefit unless otherwise specified on the Precertification Drug List or by prior authorization guidance.

Coding and Billing Codes

Listed HCPCS/J/Q Codes and corresponding drugs (partial extract)HCPCS

J3262	TOCILIZUMAB (ACTEMRA IV)
Q2055	IDCABTAGENE VICLEUCEL (ABECMA)
J0791	CRIZANLIZUMAB-TMCA (ADAKVEO)
J9042	BRENTUXIMAB (ADCETRIS)
J9029	NADOFARAGENE FIRADENOVEC-VNCG (ADSTILADRIN)
J7171	ADAMTS13 RECOMBINANT-KRHN (ADZYNMA)
J1931	LARONIDASE (ALDURAZYME)
J1552	IMMUNE GLOBULIN (HUMAN) IV (ALYGLO)
Q5126	BEVACIZUMAB-MALY (ALYMSYS)
J1426	CASIMERSEN (AMONDYS-45)

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A-codes for continuous glucose monitoring supplies/servicesHCPCS

A4238	Supply allowance for adjunctive continuous glucose monitor (CGM), includes all supplies and accessories, month supply = 1 unit of service
A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply unit of service
A9276	Ambulatory continuous glucose monitoring via subcutaneous sensor for minimum of 72 hours; physician office provided equipment and associated services

Noted drug J-codes (partial list)HCPCS

J9223	ZIIHERA
J9276	ZINPLAVA
Jo565	ZIRABEV
Q5118	ZYNLONTA
J9359	ZYNTEGLO
J3393	ZYNYZ
J9345

Codes and supply codes referencedmixed

95250	Ambulatory continuous glucose monitoring via subcutaneous sensor for minimum 72 hours; office provided equipment; sensor placement; hook-up; calibration; training; removal; printout
A4238	Supply allowance for adjunctive continuous glucose monitor (CGM), month supply = 1 unit
A4239	Supply allowance for non-adjunctive, non-implanted CGM, 1 month supply unit
A9276	Sensor; invasive (subcutaneous), disposable, for use with interstitial CGM system
A9277	Transmitter; external, for use with interstitial continuous glucose monitoring system
A9278	Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
E2102	Adjunctive continuous glucose monitor or receiver
E2103	Non-adjunctive, non-implanted continuous glucose monitor or receiver
J0139	Injection, adalimumab, 20 mg (Humira)
J0364	Injection, apomorphine hydrochloride (Apokyn)

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inv-09: CGM sensor minimum duration — minimum of 72 hours

Minimum durationContinuous glucose monitor sensor must be in place for a minimum of 72 hours

Relevant codeA9276 — ambulatory continuous glucose monitoring via subcutaneous sensor for minimum of 72 hours

Processing noteCGM supplies/services processed through pharmacy point-of-sale per DHS Preferred Drug List where applicable

inv-10: Sensor unit definition — 1 unit = 1 supply day

Sensor unit definitionOne unit = one supply day (sensor; invasive, subcutaneous, disposable)

Usage context

Provider Actions and Authorization Requirements

Prior Authorization

Precertification / Prior Approval Required

Precertification (prior authorization) is required for medications listed on the Restricted Use / Precertification Drug List (brands and generics). For drugs not on the list, FDA- or compendia-supported indications are required. Consult BCBSND Prior Authorization resources and the Preferred Drug List to determine benefit routing (medical vs pharmacy) and submission requirements.

Precertification required for listed medical drugs and equivalents; consult Prior Authorization resources
FDA or compendia-supported indications required for medications not on the list
Both brand and generic equivalents require precertification

Billing Rule

J-code Listing — Check Authorization

Quantity Limits and Supply Rules

inv-28: Continuous glucose monitor supplies — quantity limit (1)

Quantity limit (monthly)Continuous glucose monitor supplies — limit 1 unit per month

Applies toAdjunctive and non-adjunctive CGM supplies processed via A4238/A4239/A9276

RoutingProcessed through pharmacy point-of-sale per DHS Preferred Drug List guidance

inv-29: A4238/A4239/A9276 (CGM sensors/supplies) — 1 unit per day (sensor: one unit = 1 supply day); monthly supply = 1 unit

Per-day allowanceA4238/A4239/A9276 — 1 unit per day (sensor: one unit = 1 supply day); monthly supply counted as 1 unit

Codes referencedA4238 (adjunctive supply), A4239 (non-adjunctive supply), A9276 (sensor)

Site of Care Notes

Billing Rule

Bill office/ambulatory codes for CGM services

Use ambulatory/office setting professional service codes when billing for CGM placement, sensor placement, calibration, patient training and related professional services.

Example code for office-based CGM services: CPT 95250 (office-provided equipment and associated services).

Biosimilar Mentions

Billing Rule

Bill Wezlana (ustekinumab-auub) as listed biosimilar

Ustekinumab-auub (Wezlana) is listed as a biosimilar formulation in the policy code list and should be billed using the corresponding Q-code.

Biosimilar code listed: Q5137 (ustekinumab-auub, Wezlana).

Billing Rule

Bill Pyzchiva (ustekinumab-ttwe) as listed biosimilar

Ustekinumab-ttwe (Pyzchiva) is listed as a biosimilar formulation in the policy code list and should be billed using the corresponding Q-code.

Biosimilar code listed: Q9996 (ustekinumab-ttwe, Pyzchiva).

Background

This policy is an administrative listing of medications and associated billing codes that require precertification (prior approval) under the Medicaid Expansion benefit. It identifies medical‑administered drugs subject to prior authorization and also specifies codes for supplies that are processed via pharmacy point‑of‑sale, including continuous glucose monitor supplies (A4238, A4239, A9276). Providers must obtain precertification where required and follow the Preferred Drug List and applicable policy links for benefit routing and dispensing limits.

Definitions

inv-24: Medical Drug — A drug that is covered under the medical benefit and requires precertification (prior approval).

DefinitionMedical Drug — A drug that is covered under the medical benefit and requires precertification (prior approval).

Precertification referencePrior authorizations information available via BCBSND Policies & Prior_Authorization links in the policy document

Benefit routing noteMedical drugs requiring precertification are administered under the medical benefit unless processed through pharmacy per PDL

inv-25: Preferred Drug List (PDL) — List of medications preferred and processed by pharmacy point-of-sale systems; consult for additional precertification requirements and benefit routing.

DefinitionPreferred Drug List (PDL) — List of medications preferred and processed by pharmacy point-of-sale systems; consult for additional precertification requirements and benefit routing.