CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Programs for Members on the Performance Select Biosimilar Drug List

Lists drug categories and example medications that may be subject to Blue Cross Blue Shield of New Mexico prior authorization programs for members on the Performance Select Biosimilar Drug List. Intended for providers and pharmacy/billing staff to identify medications that typically require prior authorization under the prescription drug benefit.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Programs for Members on the Performance Select Biosimilar Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf a listed drug requires prior authorization or an exception review, providers or members should call the number on the member ID card or visit bcbsnm.com/provider to begin the review or prior authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~250+drug names and examples listed

multipledrug categories included (biologics, specialty, oral, injectable)

Performance Select Biosimilardrug list referenced

Policy Summary and Scope

This policy applies to providers, pharmacy staff, and billing teams working with Blue Cross Blue Shield of New Mexico members whose prescription drug benefit references the Performance Select Biosimilar Drug List. It lists drug categories and many example brand medications that may be subject to prior authorization (PA) under the member's prescription drug benefit.

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What Providers Need to Do

Prior Authorization

Prior authorization required for drugs on the Performance Select Biosimilar Drug List

Many drug categories and specific medications listed are subject to prior authorization under the member's prescription drug benefit. Providers or members should call the number on the member ID card or visit the payer website to start an exception review or prior authorization request.

Documentation Required

Exception review process

If a drug is not on the Drug List, the member or prescribing provider can request an exception review. The request may require meeting the drug's prior authorization program criteria before approval.

Exceptions may require meeting the drug's prior authorization program criteria prior to approval.

Billing Rule

Contact information requirement

If questions arise or to initiate prior authorization/exception review, use the phone number on the member's ID card or the provider site (bcbsnm.com/provider).

Defined Terms

Key definitions

Performance Select Biosimilar Drug ListThe payer's formulary/listing that identifies preferred biosimilars and other drugs that may have prior authorization or special program requirements.

Prior authorization (PA)A utilization management process requiring approval from the payer before the drug will be covered under the member's benefit.

Scope of listExamples of drug categories and specific medications for which a prior authorization program may be included as part of the prescription drug benefit; list is subject to change.

Background and Notes

The listing in this document is illustrative and subject to change. These examples do not substitute for the specific PA policy language or the member's benefit details. If a drug is not shown on the Drug List, the member or prescribing provider may request an exception review; the request may require meeting the drug's prior authorization program criteria before approval. To start the review or for questions, call the number on the member ID card or visit the provider website.