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 for BCBSND Medicaid Expansion members, and indicates processing through medical or pharmacy benefits as appropriate.

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 ActionPrecertification (Prior Approval) is required for restricted use drugs; both brand and generic equivalents require precertification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50+restricted-use drugs listed

95250, A4238…example codes included

CGM codesCGM device/supply codes named

Multipleinjection/biologic codes

Coverage Criteria and Processing Rules

Coverage criteria and processing

Covered when ALL of the following processing and coverage conditions are met:

Precertification (Prior Approval) is required for drugs listed on the Restricted Use Drug list; both brand name drugs and their generic equivalents require prior approval.

For medications not on the Restricted Use Drug list, FDA or compendia‑supported indications are required.

Prior authorization and benefit determination (medical vs. pharmacy) should follow the Preferred Drug List (PDL) and the Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit as applicable.

Medications administered by an individual that do not require professional administration are considered self‑administered and are typically not covered under the medical benefit; these items are processed through pharmacy point‑of‑sale when included on the Department of Human Services Preferred Drug List or Preferred Diabetic Supplies List.

Specific HCPCS/CPT/J‑codes enumerated in the policy are subject to the processing rules described above and must be billed according to the identified benefit (medical vs pharmacy) and any applicable prior authorization requirements.

Coverage and billing routing

Coverage stance for self‑administered medications and routing of listed codes:

Self‑administered medications are typically not covered under the medical benefit and should be billed through the pharmacy benefit when they appear on the Department of Human Services Preferred Drug List or Preferred Diabetic Supplies List.

Examples: Continuous glucose monitoring (CGM) and supply codes (e.g., 95250, A4238, A4239, A9276, A9277, A9278, E2102, E2103) included in this policy are processed via pharmacy point‑of‑sale per the Department of Human Services Preferred Diabetic Supplies List.

A broad set of injectable, biologic, clotting factor, biosimilar, and device codes listed in the policy (for example J0139 and other J‑series codes) are enumerated for routing and prior authorization purposes and are subject to the processing rules under the pharmacy or medical benefit as indicated in the policy.

Representative Codes and Code Lists

Representative J-codes from listHCPCSCovered

J3262	Tocilizumab (ACTEMRA IV)
J9042	Brentuximab (ADCETRIS)
J1552	Immune globulin (ALYGLO)

CGM and supply codesCPT | HCPCSCovered

95250	Ambulatory continuous glucose monitoring; equipment and services
A4238	Supply allowance for adjunctive CGM, 1 month supply = 1 unit

CGM and related suppliesCPT | HCPCS | mixedCovered

95250	Ambulatory continuous glucose monitoring via subcutaneous sensor for a minimum of 72 hours; office services including sensor placement, calibration, training, and printout
A4238	Supply allowance for adjunctive continuous glucose monitor (CGM), 1 month supply = 1 unit
A4239	Supply allowance for non-adjunctive, non-implanted CGM, 1 month supply = 1 unit
A9276	Sensor; invasive (subcutaneous), disposable, one unit = 1 day supply
A9277	Transmitter; external, for use with interstitial CGM system
A9278	Receiver (monitor); external, for use with interstitial CGM system
E2102	Adjunctive continuous glucose monitor or receiver
E2103	Non-adjunctive, non-implanted continuous glucose monitor or receiver

Selected injectables, biologics, factor products, biosimilars, and device codesHCPCS | CPT | mixedCovered

J0139	Injection, adalimumab, 20 mg
J1748	Injection, infliximab-dyyb, 10 mg
J7170	Injection, emicizumab-kxwh, 0.5 mg
J7200	Injection, factor IX (recombinant), Rixubis, per IU
J7205	Injection, factor VIII Fc fusion protein (Eloctate), per IU
J7527	Everolimus, oral, 0.25 mg
Q5137	Injection, ustekinumab-auub (Wezlana), biosimilar, subcutaneous, 1 mg
S1034	Artificial pancreas device system including CGM and insulin pump

Drug indications requirement

RequirementFor medications not on the Restricted Use List, FDA or compendia‑supported indications are required.

ScopeApplies when a drug is not enumerated on the BCBSND Medicaid Expansion Restricted Use List; clinical indication must match FDA labeling or accepted compendia.

Reference guidanceSee Drug Indications (Medicaid Expansion) on BCBSND for details and acceptable compendia support.

Provider Actions and Billing Guidance

Prior Authorization

Precertification required for restricted use drugs

Precertification (Prior Approval) is required for restricted use drugs; both brand name drugs and generic equivalents require precertification before coverage or dispensing.

Billing Rule

Pharmacy POS processing and self‑administered medication billing

Medications that are self‑administered (administered by an individual and not requiring professional administration) are typically not covered under the medical benefit and listed codes are processed through pharmacy point‑of‑sale according to the Department of Human Services Preferred Drug List or Preferred Diabetic Supplies List.

Examples of codes processed via pharmacy POS include 95250 (ambulatory continuous glucose monitoring) and A4238 (CGM supply allowance).
See Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for billing routing and benefit determination.

Definitions

Restricted Use Drug

DefinitionA prescription medication that may require precertification (Prior Approval) and/or be subject to a limited dispensing amount.

PrecertificationBoth brand name drugs and generic equivalents require prior authorization when listed as restricted use.

Dispensing limitsDrugs on the Restricted Use List may be subject to limited dispensing amounts as specified by policy.

Medical Drug

DefinitionA drug covered under the medical benefit that requires precertification (Prior Approval).

ActionPrior authorizations information for medical drugs can be found on the BCBSND Policies & Prior Authorization page.

RoutingMedical drugs requiring prior approval are processed under the medical benefit unless otherwise indicated.

Preferred Drug List (PDL)

DefinitionPreferred Drug List (PDL): list of medications that are preferred and processed by pharmacy point‑of‑sale systems.

UseConsult the most recent PDL to determine additional precertification/prior approval requirements and benefit (pharmacy vs medical).

Processing noteCertain codes (e.g., CGM and supplies) are processed through pharmacy point‑of‑sale per Department of Human Services PDL or Preferred Diabetic Supplies List.

Self-administered medications

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

Coverage routingSelf‑administered medications are typically billed through the pharmacy benefit rather than the medical benefit.

Policy pointerSee Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for details.

Pharmacy point of sale processing

DefinitionProcessing of certain drug and supply codes through pharmacy systems in accordance with the Department of Human Services Preferred Drug List or Preferred Diabetic Supplies List.

ExamplesCGM and supply codes included in this policy (e.g., 95250, A4238, A4239, A9276–A9278, E2102–E2103) are processed via pharmacy point‑of‑sale.

InstructionConsult DHS Preferred Drug or Preferred Diabetic Supplies Lists to determine point‑of‑sale processing and benefit determination.

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 ActionPrecertification (Prior Approval) is required for restricted use drugs; both brand and generic equivalents require precertification.

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.

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Defines drugs subject to precertification (prior approval) and limited dispensing for BCBSND Medicaid Expansion members, and indicates processing through medical or pharmacy benefits as appropriate.

Coverage Criteria and Processing Rules

Coverage criteria and processing

Covered when ALL of the following processing and coverage conditions are met:

Precertification (Prior Approval) is required for drugs listed on the Restricted Use Drug list; both brand name drugs and their generic equivalents require prior approval.

For medications not on the Restricted Use Drug list, FDA or compendia‑supported indications are required.

Coverage and billing routing

Coverage stance for self‑administered medications and routing of listed codes:

Representative Codes and Code Lists

Representative J-codes from listHCPCSCovered

J3262	Tocilizumab (ACTEMRA IV)
J9042	Brentuximab (ADCETRIS)
J1552	Immune globulin (ALYGLO)

CGM and supply codesCPT | HCPCSCovered

95250	Ambulatory continuous glucose monitoring; equipment and services
A4238	Supply allowance for adjunctive CGM, 1 month supply = 1 unit

CGM and related suppliesCPT | HCPCS | mixedCovered

95250	Ambulatory continuous glucose monitoring via subcutaneous sensor for a minimum of 72 hours; office services including sensor placement, calibration, training, and printout
A4238	Supply allowance for adjunctive continuous glucose monitor (CGM), 1 month supply = 1 unit
A4239	Supply allowance for non-adjunctive, non-implanted CGM, 1 month supply = 1 unit
A9276	Sensor; invasive (subcutaneous), disposable, one unit = 1 day supply
A9277	Transmitter; external, for use with interstitial CGM system
A9278	Receiver (monitor); external, for use with interstitial CGM system
E2102	Adjunctive continuous glucose monitor or receiver
E2103	Non-adjunctive, non-implanted continuous glucose monitor or receiver

Selected injectables, biologics, factor products, biosimilars, and device codesHCPCS | CPT | mixedCovered

J0139	Injection, adalimumab, 20 mg
J1748	Injection, infliximab-dyyb, 10 mg
J7170	Injection, emicizumab-kxwh, 0.5 mg
J7200	Injection, factor IX (recombinant), Rixubis, per IU
J7205	Injection, factor VIII Fc fusion protein (Eloctate), per IU
J7527	Everolimus, oral, 0.25 mg
Q5137	Injection, ustekinumab-auub (Wezlana), biosimilar, subcutaneous, 1 mg
S1034	Artificial pancreas device system including CGM and insulin pump

Drug indications requirement

RequirementFor medications not on the Restricted Use List, FDA or compendia‑supported indications are required.

ScopeApplies when a drug is not enumerated on the BCBSND Medicaid Expansion Restricted Use List; clinical indication must match FDA labeling or accepted compendia.

Reference guidanceSee Drug Indications (Medicaid Expansion) on BCBSND for details and acceptable compendia support.

Provider Actions and Billing Guidance

Prior Authorization

Precertification required for restricted use drugs

Precertification (Prior Approval) is required for restricted use drugs; both brand name drugs and generic equivalents require precertification before coverage or dispensing.

Billing Rule

Pharmacy POS processing and self‑administered medication billing

Examples of codes processed via pharmacy POS include 95250 (ambulatory continuous glucose monitoring) and A4238 (CGM supply allowance).
See Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for billing routing and benefit determination.

Definitions

Restricted Use Drug

DefinitionA prescription medication that may require precertification (Prior Approval) and/or be subject to a limited dispensing amount.

PrecertificationBoth brand name drugs and generic equivalents require prior authorization when listed as restricted use.

Dispensing limitsDrugs on the Restricted Use List may be subject to limited dispensing amounts as specified by policy.

Medical Drug

DefinitionA drug covered under the medical benefit that requires precertification (Prior Approval).

ActionPrior authorizations information for medical drugs can be found on the BCBSND Policies & Prior Authorization page.

RoutingMedical drugs requiring prior approval are processed under the medical benefit unless otherwise indicated.

Preferred Drug List (PDL)

DefinitionPreferred Drug List (PDL): list of medications that are preferred and processed by pharmacy point‑of‑sale systems.

UseConsult the most recent PDL to determine additional precertification/prior approval requirements and benefit (pharmacy vs medical).

Processing noteCertain codes (e.g., CGM and supplies) are processed through pharmacy point‑of‑sale per Department of Human Services PDL or Preferred Diabetic Supplies List.

Self-administered medications

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

Coverage routingSelf‑administered medications are typically billed through the pharmacy benefit rather than the medical benefit.

Policy pointerSee Medical Policy: Medications and Diabetic Supplies Payable on the Pharmacy Benefit for details.

Pharmacy point of sale processing

DefinitionProcessing of certain drug and supply codes through pharmacy systems in accordance with the Department of Human Services Preferred Drug List or Preferred Diabetic Supplies List.

ExamplesCGM and supply codes included in this policy (e.g., 95250, A4238, A4239, A9276–A9278, E2102–E2103) are processed via pharmacy point‑of‑sale.

InstructionConsult DHS Preferred Drug or Preferred Diabetic Supplies Lists to determine point‑of‑sale processing and benefit determination.