CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

Medicaid Expansion Restricted Use Drug Precertification List

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Defines drugs subject to precertification (prior approval) and limited dispensing amounts for Blue Cross Blue Shield of North Dakota Medicaid Expansion; applies to providers and pharmacy/medical benefit processing for impacted 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

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain precertification (prior approval) for any restricted use drug, including brand and generic equivalents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~250+listed restricted use drugs (brand and codes) in this partial document

Bothbrand and generic equivalents require precertification

Pharmacy POScodes processed through pharmacy point-of-sale systems

1-833-777-5779primary contact phone for language assistance

Multiple CGM codescontinuous glucose monitoring device and supply codes referenced

Coverage and Prior Authorization Criteria

Precertification / Indication Requirements

Drugs on this Restricted Use List require precertification; both brand name products and their generic equivalents require prior approval.

Precertification (Prior Approval) is required for drugs listed on the Medicaid Expansion Restricted Use List.

ALL of the following

Both brand name drugs and generic equivalents require Precertification (Prior Approval).
For medications not on this list, FDA or compendia-supported indications are required.
Medical drugs covered under the medical benefit require prior authorization per BCBSND medical prior authorization resources (see Policies & Prior Authorization).

Pharmacy benefit processing and supply allowances

Coverage routing and supply allowances for listed codes:

Self-administered medications that do not require professional administration are typically payable under the pharmacy benefit and are processed through pharmacy point-of-sale systems per the Department of Human Services Preferred Drug list.

Adjunctive and non-adjunctive continuous glucose monitor (CGM) supplies and components have specified supply allowances: A4239 = adjunctive CGM 1 month = 1 unit; A9276 = non-adjunctive CGM 1 month = 1 unit; A9277 = sensor, one unit = 1 day supply; A9278 = transmitter; E2102/E2103 = receiver/adjunctive or non-adjunctive receiver as described.

An extensive list of J-, Q-, S-, A-, and other HCPCS codes are included for processing via pharmacy POS; individual items may still require medical benefit prior authorization where applicable.

Codes and Billing References

Representative HCPCS/J-codes from listHCPCSCovered

J3262	TOCILIZUMAB (example from list)
J2507	PEGLOTICASE (example from list)

Selected injectable/biologic J-/Q-codes and descriptionsHCPCS

J1558	Immune globulin (human) subcutaneous (Xembify)
J0218	Olipudase alfa (Xenpozyme)
J0588	Incobotulinum toxin A (Xeomin)
J0775	Collagenase (Xiaflex)
J2357	Omalizumab (Xolair) healthcare administered
J9228	Ipilimumab (Yervoy)
Q2041	Axicabtagene ciloleucel (Yescarta)
J9359	Tesirine-LPYL (Zynlonta)
J3393	Betibeglogene autotemcel (Zynteglo)
J9345	Retifanlimab-DLWR (Zynyz)

Provider Requirements and Member Assistance

Prior Authorization

Precertification / Prior Authorization Requirement

Precertification (Prior Authorization) is required for restricted use drugs. Both brand name drugs and their generic equivalents require precertification prior to coverage under the medical benefit.

All restricted use drugs (brand and generic) require precertification / prior authorization.
See BCBSND Policies & Prior Authorization for medical drug prior authorization details.
Preferred Drug List (PDL) determines pharmacy vs medical benefit processing and additional prior authorization requirements: http://www.hidesigns.com/ndmedicaid/pdl/.

Billing Rule

Processing via Pharmacy Point-of-Sale; Benefit Determination

Certain drugs and diabetic supplies are processed through pharmacy point-of-sale (POS) systems per the Department of Human Services Preferred Drug List. Codes listed in this policy that represent self-administered medications, supplies or CGM supplies are billed and adjudicated via the pharmacy benefit at POS rather than the medical benefit.

Pharmacy POS processing applies per the DHS Preferred Drug List; consult the most recent PDL to determine benefit routing (pharmacy vs medical) and any precertification requirements.
Examples of codes processed via pharmacy POS include (non-exhaustive): A4238 (adjunctive CGM supply allowance, 1 month = 1 unit), A4239 (non-adjunctive non-implanted CGM supply allowance), A9276 (CGM supplies).
Self-administered medications that do not require professional administration are typically payable on the pharmacy benefit; see Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for details.

Note

Drug Indications and Coverage

If a medication is not on the restricted use list, FDA or compendia-supported indications are required for coverage determination. Consult the Drug Indications (Medicaid Expansion) guidance and the Precertification Drug List for specific drugs and codes.

Drug indications must be supported by FDA labeling or compendia when medication is not listed on the restricted use list.
Refer to the Precertification Drug List for specific drug-level prior authorization codes and requirements.

Note

Deutsch (German)

Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (1-833-777-5779) (TTY: 1-800-366-6888 oder 711).

Note

中文 (Chinese)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 (1-833-777-5779) （TTY：1-800-366-6888 或 711）。

Note

Oroomiffa (Oromo)

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (1-833-777-5779) (TTY: 1-800-366-6888 ykn 711).

Note

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (1-833-777-5779) (TTY: 1-800-366-6888 hoặc 711).

Note

Ikirundi (Bantu - Kirundi)

ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona (1-833-777-5779) (TTY: 1-800-366-6888 canke 711).

Note

العربية (Arabic)

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (1-833-777-5779) (رقم هاتف الصم والبكم: 1-800-366-6888 أو 711).

Note

Kiswahili (Swahili)

KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu (1-833-777-5779) (TTY: 1-800-366-6888 au 711).

Note

Русский (Russian)

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (1-833-777-5779) (телетайп: 1-800-366-6888 или 711).

Note

日本語 (Japanese)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 (1-833-777-5779) （TTY: 1-800-366-6888 または 711）まで、お電話にてご連絡ください。

Note

नेपाली (Nepali)

ध्यान दिनुहोस् : तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको भाषा सहायता सेवाहरू नि:शुल्क रूपमा उपलब्ध छ । फोन गर्नुहोस् (1-833-777-5779) (TTY : 1-800-366-6888 वा 711)।

Note

Français (French)

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (1-833-777-5779) (ATS : 1-800-366-6888 ou 711).

Note

한국어 (Korean)

주의 : 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. (1-833-777-5779) (TTY: 1-800-366-6888 또는 711) 번으로 전화해 주십시오.

Note

Tagalog (Tagalog - Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (1-833-777-5779) (TTY: 1-800-366-6888 o 711).

Note

Norsk (Norwegian)

MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring (1-833-777-5779) (TTY: 1-800-366-6888 eller 711).

Note

Diné Bizaad (Navajo)

Díí baa akó nínízin: Díí saad bee yán íłti'go Diné Bizaad, saad bee áká'ání da'á wo'dę́ę́, t'áá jiik'eh, éí ná hólǫ́, kojį'hódíílnih (1-833-777-5779) (TTY: 1-800-366-6888 éí doodagó 711).

Definitions and Terminology

Restricted Use Drug — Definition

TermRestricted Use Drug

DefinitionA Prescription Medication or Drug that may require Precertification (Prior Approval) and/or be subject to a limited dispensing amount.

ActionBoth brand name drugs and generic equivalents require precertification (Prior Approval).

Medical Drug — Definition

TermMedical Drug

DefinitionA drug that is covered under the medical benefit and requires Precertification (Prior Approval).

ReferencePrior authorizations information for medical drugs available on BCBSND Policies & Prior Authorization.

Preferred Drug List (PDL) — Definition

TermPreferred Drug List (PDL)

DefinitionA list of medications that are preferred and processed by pharmacy point-of-sale systems; consult the most recent PDL to determine additional Precertification or Prior Approval requirements and benefit processing.

Linkhttp://www.hidesigns.com/ndmedicaid/pdl/

Self-administered medications — Definition

TermSelf-administered medications

DefinitionMedications administered by an individual that do not require professional administration by a healthcare provider and are not typically covered under the medical benefit.

ReferenceSee Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for pharmacy coverage guidance.

Continuous glucose monitoring supplies — Definition & allowances

TermContinuous glucose monitoring supplies

DefinitionDevice components and supplies for continuous glucose monitoring (sensor, transmitter, receiver) with specified supply allowances (e.g., A4238, A4239, A9276, A9277, A9278, E2102, E2103); allowances differ for adjunctive and non-adjunctive devices (1 month supply = 1 unit of service for certain codes).

Examples of codesA4238, A4239, A9276, A9277, A9278, E2102, E2103, S1030-S1037 (selected CGM/device codes)

Language assistance services — Definition

TermLanguage assistance services

DefinitionFree language translation and interpretation services provided to members in multiple languages at no cost.

ContactCall 1-833-777-5779 (TTY: 1-800-366-6888 or 711) for assistance in listed languages (examples include German, Chinese, Oromo).

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

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain precertification (prior approval) for any restricted use drug, including brand and generic equivalents.

SourceLink

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Medicaid Expansion Restricted Use Drug Precertification List

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - North Dakota policy alerts

Know when Blue Cross Blue Shield - North Dakota releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage and Prior Authorization Criteria

Precertification / Indication Requirements

Drugs on this Restricted Use List require precertification; both brand name products and their generic equivalents require prior approval.

Precertification (Prior Approval) is required for drugs listed on the Medicaid Expansion Restricted Use List.

ALL of the following

Both brand name drugs and generic equivalents require Precertification (Prior Approval).
For medications not on this list, FDA or compendia-supported indications are required.
Medical drugs covered under the medical benefit require prior authorization per BCBSND medical prior authorization resources (see Policies & Prior Authorization).

Pharmacy benefit processing and supply allowances

Coverage routing and supply allowances for listed codes:

An extensive list of J-, Q-, S-, A-, and other HCPCS codes are included for processing via pharmacy POS; individual items may still require medical benefit prior authorization where applicable.

Codes and Billing References

Representative HCPCS/J-codes from listHCPCSCovered

J3262	TOCILIZUMAB (example from list)
J2507	PEGLOTICASE (example from list)

Selected injectable/biologic J-/Q-codes and descriptionsHCPCS

J1558	Immune globulin (human) subcutaneous (Xembify)
J0218	Olipudase alfa (Xenpozyme)
J0588	Incobotulinum toxin A (Xeomin)
J0775	Collagenase (Xiaflex)
J2357	Omalizumab (Xolair) healthcare administered
J9228	Ipilimumab (Yervoy)
Q2041	Axicabtagene ciloleucel (Yescarta)
J9359	Tesirine-LPYL (Zynlonta)
J3393	Betibeglogene autotemcel (Zynteglo)
J9345	Retifanlimab-DLWR (Zynyz)

Provider Requirements and Member Assistance

Prior Authorization

Precertification / Prior Authorization Requirement

Precertification (Prior Authorization) is required for restricted use drugs. Both brand name drugs and their generic equivalents require precertification prior to coverage under the medical benefit.

All restricted use drugs (brand and generic) require precertification / prior authorization.
See BCBSND Policies & Prior Authorization for medical drug prior authorization details.
Preferred Drug List (PDL) determines pharmacy vs medical benefit processing and additional prior authorization requirements: http://www.hidesigns.com/ndmedicaid/pdl/.

Billing Rule

Processing via Pharmacy Point-of-Sale; Benefit Determination

Pharmacy POS processing applies per the DHS Preferred Drug List; consult the most recent PDL to determine benefit routing (pharmacy vs medical) and any precertification requirements.
Examples of codes processed via pharmacy POS include (non-exhaustive): A4238 (adjunctive CGM supply allowance, 1 month = 1 unit), A4239 (non-adjunctive non-implanted CGM supply allowance), A9276 (CGM supplies).
Self-administered medications that do not require professional administration are typically payable on the pharmacy benefit; see Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for details.

Note

Drug Indications and Coverage

Drug indications must be supported by FDA labeling or compendia when medication is not listed on the restricted use list.
Refer to the Precertification Drug List for specific drug-level prior authorization codes and requirements.

Note

Deutsch (German)

Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (1-833-777-5779) (TTY: 1-800-366-6888 oder 711).

Note

中文 (Chinese)

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 (1-833-777-5779) （TTY：1-800-366-6888 或 711）。

Note

Oroomiffa (Oromo)

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (1-833-777-5779) (TTY: 1-800-366-6888 ykn 711).

Note

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (1-833-777-5779) (TTY: 1-800-366-6888 hoặc 711).

Note

Ikirundi (Bantu - Kirundi)

ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona (1-833-777-5779) (TTY: 1-800-366-6888 canke 711).

Note

العربية (Arabic)

Note

Kiswahili (Swahili)

KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu (1-833-777-5779) (TTY: 1-800-366-6888 au 711).

Note

Русский (Russian)

Note

日本語 (Japanese)

Note

नेपाली (Nepali)

Note

Français (French)

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (1-833-777-5779) (ATS : 1-800-366-6888 ou 711).

Note

한국어 (Korean)

주의 : 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. (1-833-777-5779) (TTY: 1-800-366-6888 또는 711) 번으로 전화해 주십시오.

Note

Tagalog (Tagalog - Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (1-833-777-5779) (TTY: 1-800-366-6888 o 711).

Note

Norsk (Norwegian)

MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring (1-833-777-5779) (TTY: 1-800-366-6888 eller 711).

Note

Diné Bizaad (Navajo)

Definitions and Terminology

Restricted Use Drug — Definition

TermRestricted Use Drug

DefinitionA Prescription Medication or Drug that may require Precertification (Prior Approval) and/or be subject to a limited dispensing amount.

ActionBoth brand name drugs and generic equivalents require precertification (Prior Approval).

Medical Drug — Definition

TermMedical Drug

DefinitionA drug that is covered under the medical benefit and requires Precertification (Prior Approval).

ReferencePrior authorizations information for medical drugs available on BCBSND Policies & Prior Authorization.

Preferred Drug List (PDL) — Definition

TermPreferred Drug List (PDL)

Linkhttp://www.hidesigns.com/ndmedicaid/pdl/

Self-administered medications — Definition

TermSelf-administered medications

DefinitionMedications administered by an individual that do not require professional administration by a healthcare provider and are not typically covered under the medical benefit.

ReferenceSee Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for pharmacy coverage guidance.

Continuous glucose monitoring supplies — Definition & allowances

TermContinuous glucose monitoring supplies

Examples of codesA4238, A4239, A9276, A9277, A9278, E2102, E2103, S1030-S1037 (selected CGM/device codes)

Language assistance services — Definition

TermLanguage assistance services

DefinitionFree language translation and interpretation services provided to members in multiple languages at no cost.

ContactCall 1-833-777-5779 (TTY: 1-800-366-6888 or 711) for assistance in listed languages (examples include German, Chinese, Oromo).