Medicaid Expansion Restricted Use Drug Precertification List
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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.
No material clinical or coverage changes in this revision.
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.
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
| 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) |
| 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 |
| 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) |
Provider Actions and Authorization Requirements
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
J-code Listing — Check Authorization
Multiple HCPCS / J-codes are referenced in this policy for injectable drugs and biologics. Verify authorization requirements and include J-code(s) on prior authorization requests to ensure correct processing and to avoid denials.
CGM Supplies — Processing and Codes
Continuous glucose monitoring (CGM) supplies and related codes are processed through the pharmacy benefit per Department of Human Services direction. Confirm processing route and include appropriate supply codes on requests or claims.
- A4238 — Supply allowance for adjunctive CGM, month = 1 unit
- A4239 — Supply allowance for non-adjunctive, non-implanted CGM, month = 1 unit
- A9276 — Sensor; invasive, disposable, one unit = 1 supply day
- A9277 — Transmitter; external
- A9278 — Receiver (monitor); external
- E2102 — Adjunctive CGM or receiver
- E2103 — Non-adjunctive, non-implanted CGM or receiver
Language Assistance Contact
Language assistance is available to providers and members. Contact the BCBSND language services line for free interpreter services.
- Provider action: Offer language assistance when needed
- Members/providers: Call 1-833-777-5779 (TTY 1-800-366-6888 or 711)
Provider Actions — None Otherwise Stated / Denial Risk
No additional provider actions or denial triggers are explicitly stated in this section beyond those above. Providers should follow prior authorization guidance, include required codes, and confirm benefit routing (medical vs pharmacy) to reduce risk of claim denial.
- No other specific denial triggers stated in this section
- Follow PA requirements and include required documentation and codes to avoid denials
Quantity Limits and Supply Rules
Site of Care Notes
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
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).
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
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