2025 Drug List (Pharmacy Benefit) — Coverage Criteria
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Governs the Blue Cross Blue Shield of New Mexico 2025 pharmacy drug list: which outpatient drugs are covered under the pharmacy benefit, tiering, specialty drugs, and prior authorization/step therapy processes for members and providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Flags
General pharmacy drug coverage
Covered when plan documents and the BCBSNM Drug List indicate coverage and any Special Requirements (PA, ST, QL, AC, BH, NM, SP) are satisfied.
Payment tiers and exceptions vary by plan; refer to member plan materials and the Special Requirements column on the Drug List.
Formulary coverage flags
Coverage and utilization-management flags shown on formulary entries determine prior authorization, quantity limits, specialty handling, and step-therapy requirements.
When a flag is present on the Drug List, follow the associated operational rule (e.g., submit PA; adhere to QL; use specialty pharmacy for SP).
Formulary coverage entries
Each formulary line shows the plan administrative stance and any quantity or program limits that apply to coverage processing.
The Drug List is an item-level listing used to determine coverage and administrative controls; clinical diagnosis-level criteria are not included in the line items in this excerpt.
Formulary coverage with quantity/program limits
Coverage and limits are applied per product line when prescriptions conform to the listed Drug Tier and any program/quantity restrictions.
Examples include oncology and specialty agents that carry QL and SP designations; refer to the specific line for the exact QL or pack limits.
Product-specific coverage (list entries)
Coverage stance and operational controls are product-specific; the following captures representative items and the controls that apply.
See each product line for the exact Requirement/Limits and quantity/time period.
Drugs not shown on the BCBSNM 2025 Drug List are not covered. In addition, certain formulations or presentations may be excluded from coverage by plan design — for example, repackaged versions of marketed products, compounded preparations, and non–FDA‑approved drugs are not covered under the pharmacy benefit unless otherwise specified in the member’s plan materials. Refer to the member’s benefit plan and the Drug List for the definitive coverage determination and for any product‑specific Special Requirements (e.g., PA, QL, ST, AC, BH, NM).
Most pharmacy benefits limit outpatient fills to a 30‑day supply, with some plans allowing up to a 90‑day supply for maintenance medications (conditions such as hypertension, diabetes, or hyperlipidemia). Prior authorization (noted as PA in the Special Requirements column) may be required for selected drugs; providers must obtain PA and submit supporting documentation when the Drug List indicates PA to avoid claim denial.
The Drug List uses the Requirements/Limits field to indicate coverage controls for specific product presentations. Several azithromycin presentations and many antiretroviral combination products are listed with a Requirements/Limits code of NM in the formulary rows; when shown this status is applied at the product‑presentation level and may restrict coverage for that specific strength or formulation (e.g., azithromycin tabs/suspensions with Requirements/Limits = NM).
Many antiretroviral and other combination products also show accompanying QL values (for example, QL (30 tablets/30 days)) and these quantity limits must be observed when dispensing. When a product line shows both NM and a QL entry the plan’s processing rules for that combination apply to claims for that exact presentation.
This Drug List extract does not contain standalone medical exclusion statements for broad drug classes; instead, most entries specify operational controls (tier assignment and Requirements/Limits codes such as PA, QL, SP, AC, ST, and NM) that govern coverage processing for each listed product presentation. Where no Requirements/Limits are shown, coverage follows the member’s benefit plan and tier designation.
Some individual entries are explicitly annotated with NM in the Requirements/Limits column (examples include certain vaccine presentations and some anti‑infective presentations listed elsewhere in the Drug List). Within this formulary extract NM functions as a product‑level utilization/coverage flag that can restrict coverage for that presentation; review the specific line item when adjudicating claims.
Quantity limits are applied per product where noted (examples in the Drug List include QL (60 tablets/180 days) for some macrolide presentations and many other product‑specific QL values such as QL (30 tablets/30 days)). Requests exceeding the listed QL or lacking required PA/SP approvals may be denied per the plan’s adjudication rules.
Coverage for each listed drug presentation is determined by three elements: (1) the drug appears on the BCBSNM Drug List; (2) the member’s benefit plan includes coverage for that drug form (pharmacy vs medical benefit and applicable tier); and (3) any Special Requirements shown on the Drug List are met. Operators processing claims should follow the Special Requirements codes on the product line — for example, PA (prior authorization), QL (quantity limit), SP (specialty program/specialty pharmacy), AC (administrative/ACA‑related coverage condition), and ST (step therapy) — when determining coverage eligibility.
Prescribers and dispensing pharmacies must document indication, strength/formulation, and requested quantity consistent with the Drug List entry. For products marked PA or PA, QL (e.g., selected specialty cardiovascular and pulmonary agents and many high‑cost specialty drugs), submit the prior authorization and supporting clinical documentation before dispensing. For items with explicit QL values, dispense only up to the listed quantity for the specified time period unless an approved prior authorization or exception is obtained.
If a drug is not shown on the Drug List, is a repackaged or non‑FDA product, or is a compounded product excluded by the member’s plan, it will not be covered. Members or providers may request Drug List exceptions or step‑therapy exceptions per the processes described in the benefit materials; expedited reviews are available when medically necessary as defined by plan procedures.
Drug Listings, Codes and Quantity Details
| amoxicillin | amoxicillin (trihydrate) various strengths and formulations |
| amoxicillin/clavulanate | amoxicillin & clavulanate various strengths and formulations (Augmentin) |
| penicillin V potassium | penicillin v potassium tab and suspension |
| cefaclor | cefaclor cap 250 mg, 500 mg |
| cefadroxil | cefadroxil tab/cap and susp |
| azithromycin | azithromycin formulations and tablets (Zithromax) with NM and QL notes |
| clarithromycin | clarithromycin formulations |
| fidaxomicin | DIFICID - fidaxomicin tab 200 mg and suspension |
| doxycycline | doxycycline hyclate/monohydrate various formulations |
| omidacycline | NUZYRA - omadacycline tosylate tab 150 mg |
| BIKTARVY | bictegravir-emtricitabine-tenofovir af tab 30-120-15 mg, 50-200-25 mg |
| CIMDUO | lamivudine-tenofovir disoproxil fumarate tab 300-300 mg |
| COMPLERA | emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg |
| DARUNAVIR | darunavir tab 600 mg; darunavir tab 800 mg |
| DELSTRIGO | doravirine-lamivudine-tenofovir df tab 100-300-300 mg |
| DESCOVY | emtricitabine-tenofovir alafenamide fumarate tab (various strengths) |
| DOVATO | dolutegravir sodium-lamivudine tab 50-300 mg |
| EDURANT | rilpivirine hcl tab 25 mg; oral suspension |
| EFAVIRENZ | efavirenz tabs and combination products (various) |
| EMTRIVA | emtricitabine caps/solution |
| N/A | This section contains drug names and formulations; no CPT/HCPCS/ICD codes are listed in these chunks. |
| ELESTRIN | estradiol gel 0.06% (0.52 mg/0.87 gm metered-dose pump) |
| Estrogel | estradiol gel 0.06% (0.75 mg/1.25 gm metered-dose pump) |
| Estrace | estradiol tablet 0.5 mg, 1 mg, 2 mg |
| Divigel | estradiol transdermal gel (multiple strengths) |
| Vivelle-dot | estradiol transdermal patch (twice weekly strengths) |
| Climara | estradiol transdermal patch (weekly strengths) |
| Delestrogen | estradiol valerate IM in oil (10, 20, 40 mg/ml) |
| EVAMIST | estradiol transdermal spray 1.53 mg/spray |
| MENEST | esterified estrogens tablets (various strengths) |
| MENOSTAR | estradiol transdermal patch weekly 14 mcg/24hr |
| 140 mg/ml | REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml |
| 420 mg/3.5ml | REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous soln cartridge/infusor 420 mg/3.5ml |
| 0.1 mg/0.1ml; 0.15 mg/0.15ml; 0.3 mg/0.3ml | AUVI-Q - epinephrine solution auto-injector strengths |
| 5 mg/5ml | CORLANOR - ivabradine hcl oral soln 5 mg/5ml |
| 0.6 mg/ml | TYVASO - treprostinil inhalation solution 0.6 mg/ml |
| CAMZYOS - mavacamten cap 5 mg | mavacamten capsule 5 mg |
| CORLANOR - ivabradine hcl oral soln 5 mg/5ml | ivabradine oral solution 5 mg/5 ml |
| ENTRESTO - sacubitril-valsartan tab 24-26 mg, 49-51 mg, 97-103 mg | sacubitril-valsartan tablets various strengths |
| VYNDAMAX - tafamidis cap 61 mg | tafamidis 61 mg capsule |
| VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg | tafamidis meglumine 20 mg capsule |
| WINREVAIR - sotatercept-csrk for subcutaneous soln kit | sotatercept subcutaneous solution kit |
| sildenafil citrate tab 25 mg, 50 mg, 100 mg (Viagra) | sildenafil tablets |
| tadalafil tab 2.5 mg; 5 mg (Cialis); 10 mg, 20 mg | tadalafil tablets various strengths |
| avanafil tab 50 mg, 100 mg, 200 mg (Stendra) | avanafil tablets |
| ADVAIR HFA - fluticasone-salmeterol inhal aerosol | fluticasone-salmeterol HFA inhaler |
| ALBU/VENTOLIN HFA - albuterol sulfate inhal aerosol 108 mcg/act | albuterol HFA inhaler |
| TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol | triple combination inhaler |
| KALYDECO - ivacaftor | ivacaftor formulations |
| ORKAMBI - lumacaftor-ivacaftor | lumacaftor-ivacaftor formulations |
| ALYFTREK - vanzacaftor-tezacaftor-deutivacaftor | triple CF modulator formulations |
| ALYFTREK | vanzacaftor-tezacaftor-deutivacaftor tab 4-20-50 mg; 10-50-125 mg (QL and SP noted) |
| KALYDECO | ivacaftor tab 150 mg and packets (QL and SP noted) |
| ORKAMBI | lumacaftor-ivacaftor tabs/granules (QL and SP noted) |
| SYMDEKO | tezacaftor-ivacaftor & ivacaftor tabs (QL and SP noted) |
| TRIKAFTA | elexacaftor-tezacaftor-ivacaftor & ivacaftor formulations (QL and SP noted) |
| Golytely | peg 3350-kcl-na bicarb-nacl-na sulfate for solution (various sizes) with AC or no limit |
| PEG-PREP | bisacodyl tab & PEG prep kit |
| SUTAB | sodium sulfate tablets (bowel prep) |
| EMEND | aprepitant for oral suspension 125 mg (QL listed) |
| ONDANSETRON | ondansetron formulations (tabs, soln, ODT) |
| MOVANTIK | naloxegol oxalate tabs with QL |
| CREON | pancrelipase DR capsules (multiple strengths) |
| ZENPEP | pancrelipase DR capsules (multiple strengths) |
| GATTEX | teduglutide injection kit (PA, SP) |
| SKYRIZI | risankizumab cartridges (QL and SP noted) |
| TREMFYA | guselkumab prefilled syringe/auto-injector (QL, SP) |
| MYRBETRIQ | mirabegron formulations (granules, ER tabs) |
| metronidazole vaginal gel 0.75% | metronidazole vaginal gel 0.75% |
| miconazole nitrate vaginal suppos 200 mg | miconazole nitrate vaginal suppos 200 mg |
| NUVESSA metronidazole vaginal gel 1.3% | NUVESSA - metronidazole vaginal gel 1.3% |
| nonoxynol-9 gel 3% | OPTIONS GYNOL II VAGINAL - nonoxynol-9 gel 3% |
| PHEXXI | PHEXXI - lactic acid-citric acid-potassium bitartrate gel 1.8-1-0.4% |
| PREMARIN vaginal cream | PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm |
| alfuzosin hcl tab er 24hr 10 mg | alfuzosin hcl tab er 24hr 10 mg (Uroxatral) |
| CYSTAGON - cysteamine cap 50 mg, 150 mg | CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mg |
| dutasteride cap 0.5 mg | dutasteride cap 0.5 mg (Avodart) |
| ELMIRON - pentosan polysulfate 100 mg | ELMIRON - pentosan polysulfate sodium caps 100 mg |
| FILSPARI - sparsentan tab 200 mg, 400 mg | FILSPARI - sparsentan tab 200 mg, 400 mg |
| alprazolam tab er 24hr 0.5 mg - 3 mg | alprazolam tab er 24hr 0.5 mg, 1 mg, 2 mg, 3 mg (Xanax xr) |
| alprazolam tab 0.25 mg - 2 mg | alprazolam tab 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax) |
| buspirone hcl tab 5 mg - 30 mg | buspirone hcl tab 5 mg, 10 mg, 15 mg, 30 mg |
| diazepam conc 5 mg/ml | diazepam conc 5 mg/ml |
| fluoxetine hcl cap delayed release 90 mg | FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg |
| escitalopram oxalate tab 5 mg - 20 mg | escitalopram oxalate tab 5 mg, 10 mg, 20 mg (Lexapro) |
| desvenlafaxine succinate tab er 24hr 25-100 mg | desvenlafaxine succinate tab er 24hr 25 mg, 50 mg, 100 mg (Pristiq) |
| aripiprazole oral solution 1 mg/ml | aripiprazole oral solution 1 mg/ml |
| aripiprazole orally disintegrating tab 10 mg, 15 mg | aripiprazole orally disintegrating tab 10 mg, 15 mg |
| aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg | aripiprazole tabs (Abilify) |
| clozapine orally disintegrating tab 12.5 mg - 200 mg | CLOZAPINE ODT - clozapine orally disintegrating tabs various strengths |
| iloperidone tab various & titration packs | FANAPT and FANAPT TITRATION PACKS |
| quetiapine fumarate tabs (IR and XR) various strengths | quetiapine fumarate (Seroquel, Seroquel XR) |
| risperidone tabs and ODT and solution | risperidone formulations (Risperdal) |
| brexpiprazole tab 0.25 mg - 4 mg | REXULTI - brexpiprazole tabs |
| 300 mg, 400 mg | quetiapine fumarate tab strengths (Seroquel) |
| 0.25 mg - 4 mg | brexpiprazole tab strengths (Rexulti) |
| 50 mg/ml | clozapine suspension strength (Versacloz) |
| 1.5 mg - 6 mg | cariprazine cap strengths (Vraylar) |
| 20 mg - 80 mg | ziprasidone cap strengths (Geodon) |
| 5 mg - 30 mg | amphetamine-dextroamphetamine ER capsule strengths (Adderall XR) |
| 50 mg/3ml | caffeine citrate oral solution 60 mg/3ml |
| 10 mg - 200 mg | armodafinil/modafinil strengths (Nuvigil/Provigil) |
| 10 mg - 70 mg | lisdexamfetamine strengths (Vyvanse) |
| 120 mg | orlistat cap 120 mg (Xenical/Orlistat) |
| 0.25 mg/0.5ml - 1 mg/0.5ml | semaglutide injection strengths (Wegovy) |
| 2.5 mg/0.5ml - 15 mg/0.5ml | tirzepatide injection strengths (Zepbound) |
| MAVENCLAD - cladribine tab therapy pack 10 mg (5 tabs) | Drug formulary line item as listed |
| MAYZENT - siponimod fumarate tab 0.25 mg | Drug formulary line item as listed |
| NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap 20-10 mg | Requirements: BH, PA, QL (60 capsules/30 days) |
| PLEGRIDY - peginterferon beta-1a soln auto-injector 125 mcg/0.5ml | Requirements: QL (2 pens/28 days), SP |
| VUMERITY - diroximel fumarate capsule delayed release 231 mg | Requirements: QL (120 capsules/30 days), SP |
Prior Authorization, Step Therapy, Documentation and Denial Risks
Obtain prior authorization when 'PA' is listed
Prior authorization may be required for certain drugs; when commonly required the Drug List marks the product with 'PA' under the Special Requirements column. Providers must submit a prior authorization request and obtain approval before the medication will be covered when 'PA' is listed.
- If a product line shows 'PA' the prescriber must submit a prior authorization prior to dispensing.
- Some plans may require PA on additional medications beyond those noted; verify member benefit plan details.
PA and specialty handling for inhaled antibiotics
Inhaled aminoglycoside products (e.g., TOBI, TOBI PODHALER, KITABIS PAK, ARIKAYCE) are annotated with PA, QL and specialty flags — providers must obtain prior authorization and follow specialty routing/quantity limits before dispensing.
- TOBI/TOBI PODHALER — QL and SP indicated; PA required where listed.
- ARIKAYCE — listed with QL and SP; PA must be obtained per the Drug List.
Prior authorization required for select products (e.g., PEGASYS)
Certain listed products (for example, PEGASYS entries) are shown with 'PA' (and often 'SP'); providers must submit prior authorization for these products as indicated on the formulary line.
- PEGASYS (peginterferon alfa-2a) entries explicitly list Requirements/Limits = PA, SP; PA is required before coverage.
- Check the Special Requirements column on each product line for PA notation.
PA and specialty program requirements for specialty oncology drugs
Many specialty oncology and high-cost agents are designated 'SP' and often require prior authorization and adhere to quantity limits (QL); providers must obtain PA and route dispensing through specialty pharmacy when indicated.
- Examples: ALUNBRIG, ALECENSA, AKEEGA and other oncology agents list QL and SP and require PA or programmatic management.
- Follow the Requirements/Limits (PA, QL, SP) shown on each drug line for authorization and site-of-care routing.
Obtain PA for testosterone products when listed
Multiple testosterone products list 'PA' in the Requirements/Limits field; providers must obtain prior authorization before dispensing these testosterone formulations.
- Examples include testosterone cypionate and testosterone enanthate injections and topical gels noted with Requirements/Limits = PA.
- Dispense only after an approved prior authorization when 'PA' is present.
PA and QL required for select specialty/brand drugs
Selected specialty or brand products (e.g., MOUNJARO, OZEMPIC, MIFEPRISTONE/Korlym, RYBELSUS) are marked with 'PA' and specific quantity limits; providers must submit prior authorization and adhere to the listed QL.
- MOUNJARO — Requirements/Limits = PA, QL (e.g., 4 pens/180 days or 4 pens/28 days depending on strength).
- OZEMPIC — Requirements/Limits = PA, QL (1 pen/28 days or volume-based QL as shown).
- MIFEPRISTONE (Korlym) — Requirements/Limits = PA, QL (120 tablets/30 days), SP.
PA required for select GLP-1 and endocrine agents
Certain GLP-1 receptor agonists and other specialty endocrine agents (e.g., TRULICITY, RYBELSUS) are labeled 'PA' (often with QL); prescribers must obtain prior authorization as indicated on the formulary entries.
- TRULICITY — Requirements/Limits = PA, QL (4 pens/28 days).
- RYBELSUS — Requirements/Limits = PA, QL (30 tablets/180 days for 3 mg; 30 tablets/30 days for 7/14 mg).
PA required for listed specialty drugs — verify PA/QL/SP
Many specialty and high‑cost products across the Drug List show 'PA' in Requirements/Limits; providers must submit prior authorization requests and comply with any specialty pharmacy (SP) routing and quantity limits noted on the product line.
- Verify PA, QL, and SP flags on each drug line prior to dispensing.
- Specialty-designated items (SP) typically require specialty pharmacy distribution.
Follow BH prior authorization and controls for CNS agents
Many behavioral health and central nervous system agents are designated 'BH' and some include 'ST' or 'PA'; providers must follow BH prior authorization processes and any quantity or step therapy controls listed.
- Examples include aripiprazole, clozapine, risperidone formulations marked BH with QL and sometimes ST.
- When 'BH' is listed, behavioral health prior authorization requirements apply.
Adhere to step therapy ('ST') or submit exception
Step therapy is indicated by 'ST' in the Special Requirements column for affected products; prescribers may submit step therapy exception requests and should document prior trials or clinical rationale when requesting an exception.
- If 'ST' appears on a drug line, the member may need to trial preferred therapy first.
- Step therapy exception requests are processed within three business days (or 24 hours if expedited for urgent conditions).
SP-designated specialty drugs — follow PA/QL where shown
Some specialty drugs are marked 'SP' and show QL limits; while SP indicates specialty handling, explicit step therapy sequences are not provided in this excerpt — providers must follow PA/QL/SP annotations for coverage and dispensing.
- SP designation may imply specialty pharmacy routing and program requirements.
- Where 'PA' is also listed, obtain authorization prior to dispensing.
No explicit step sequences provided in this excerpt
No explicit multi-step therapy sequences are specified in the provided Drug List excerpts; where step therapy applies it is indicated by 'ST' on the product line and must be followed or an exception requested.
- Providers should not assume a specific step sequence unless 'ST' and the required prior step are specified on the formulary line.
- Use the exception process if clinical reasons preclude the required step.
PA and SP noted for select pulmonary/PAH therapies
Some specialty pulmonary and PAH therapies are marked 'SP' and 'PA' which may imply specialty pharmacy routing and prior authorization requirements; explicit step therapy rules are not present in these chunks, so obtain PA and follow specialty dispensing instructions.
- ORENITRAM and TYVASO list PA and QL and are SP — obtain PA and adhere to QL prior to dispensing.
- CAMZYOS, OPSUMIT and other PAH agents list PA/QL/SP — follow product-specific requirements.
Honor starter pack / initiation quantity limits
Starter packs and limited starter kit quantity limits are shown for some specialty products (e.g., MAYZENT starter packs, ZEPOSIA starter kits); providers must dispense starter packs only within the listed QL for initiation.
- MAYZENT starter pack — Requirements/Limits = QL shown for starter pack; dispense per pack limit.
- ZEPOSIA 7‑DAY STARTER PACK — Requirements/Limits = QL (7 capsules/180 days), SP.
Non‑listed drugs and missing PA risk denial
Drugs not shown on the Drug List are not covered under the pharmacy benefit; failure to obtain required prior authorization for drugs marked 'PA' can result in claim denial or lack of coverage.
- Confirm the drug is on the Drug List and confirm any 'PA' requirement before dispensing.
- If a PA is required and not approved, the claim may be denied and member may be financially responsible.
Azithromycin QL/NM — risk of denial if limits not met
Azithromycin formulations include 'NM' flags and quantity limits (e.g., tablet QL); claims that do not meet the listed Requirements/Limits or exceed QL may be subject to denial.
- Azithromycin tablets show QL (e.g., 60 tablets/180 days); dispense per QL or obtain PA/documentation if seeking greater quantity.
- Verify the specific presentation and Requirements/Limits on the formulary line.
Denial risk for inhaled aminoglycosides without PA/within QL
Inhaled aminoglycoside products (TOBI, TOBI PODHALER, KITABIS PAK, ARIKAYCE) list PA, QL and SP flags; absence of prior authorization or requests exceeding the QL may trigger denial.
- TOBI nebu soln — QL (56 containers/56 days), SP; PA required where listed.
- ARIKAYCE — QL (e.g., 235.2 mLs/28 days), SP — obtain PA and follow QL to avoid denial.
PA/SP/AC flags can trigger denials if not satisfied
Entries marked with PA, SP, or AC indicate requirements that can trigger prior authorization or special processing; failure to meet these listed controls can lead to benefit denial.
- Products with 'AC' (administrative/approval criteria) may require supporting documentation at time of claim or PA submission.
- When PA or SP is shown, obtain authorization and route dispensing accordingly to prevent denial.
Exceeding QL or ignoring SP risks denial
Claims that exceed quantity limits (QL) or request specialty program dispensing (SP) without authorization are subject to denial; providers should verify and adhere to QL values on each drug line.
- Quantity limits are product‑specific (e.g., 30 tablets/30 days, 6 syringes/28 days); requests above these limits require PA or documentation.
- Specialty drugs marked SP require specialty pharmacy handling; failing to use SP channel may affect coverage.
PA and documentation required for select specialty agents (REPATHA, ORENITRAM)
Medications listed with 'PA' or 'PA, QL' (for example, REPATHA/evolocumab, ORENITRAM) require prior authorization and documentation to support medical necessity; requests lacking required PA or supporting documentation risk denial.
- REPATHA — Requirements/Limits = PA, QL (6 syringes/28 days) — obtain PA and document indication.
- ORENITRAM — Requirements/Limits = PA, QL (300 tablets/30 days), SP — PA required prior to coverage.
Initial Therapy and Specialty Drug Controls
Specialty injectable/tablet initial coverage notes
Coverage and utilization management for cardiovascular and related outpatient drugs are governed by the formulary annotations shown.
Examples include REPATHA, CAMZYOS, ENTRESTO sprinkle, ORENITRAM and other PAH/cardiovascular agents that list PA/QL/SP.
PA requirements for specialty/high-cost agents
Prior authorization is expected for many specialty/high-cost cardiovascular and related agents listed with PA/QL/SP.
Examples in the formulary include REPATHA (PA, QL), CAMZYOS (PA, QL, SP), OPSUMIT (PA, QL, SP), ORENITRAM (PA, QL, SP).
Operational initial therapy rules
When no explicit clinical initial-therapy criteria are listed, operational controls govern coverage.
The Drug List entries in this excerpt do not include detailed clinical eligibility criteria — follow the Requirements/Limits annotations for operational actions.
Initial therapy and dispensing controls
Formulary initial coverage is determined by the listed Drug Tier and Requirements/Limits annotations.
Examples: CF modulators and other specialty agents list QL and SP values that limit initial dispensing until prior authorization and specialty routing are confirmed.
Initial therapy controls
Utilization controls at therapy initiation include prior authorization, behavioral health routing, specialty pharmacy, step edits, and starter-pack limits as indicated.
Where step therapy (ST) or behavioral health (BH) is noted, prior steps or BH authorization must be met before coverage; starter packs and limited QLs may restrict initial dispensing.
Step Therapy Rules and Tables
| Step therapy summary | Implication for provider / member | Source note |
|---|---|---|
| Step Therapy (ST) is used when the benefit plan requires trial of a preferred, cost‑effective first‑line medication before coverage of the listed drug | ||
| Providers may submit a step therapy exception request if the preferred first‑line drug is not appropriate; BCBSNM will notify the prescriber/member of the decision within three business days (or 24 hours for expedited reviews) | ||
| If ST is commonly required for a medication it is noted with 'ST' in the Special Requirements column of the Drug List |
| Flag / Code | Meaning / Effect on coverage | Example from formulary |
|---|---|---|
| AC (Approval Criteria) | ||
| Indicates administrative/clinical criteria that must be met (may function like a step or documentation requirement prior to coverage) | ||
| Some antiretroviral entries show 'AC' alongside NM and QL designations (see ARV listings) |
| SP marker | Operational effect | Formulary example |
|---|---|---|
| SP (Specialty) designation | ||
| Product typically requires specialty pharmacy handling or program management; may be subject to PA and QL | ||
| PALFORZIA and many oncology agents are listed with Requirements/Limits = SP |
| Product group / example | Requirement | Provider action |
|---|---|---|
| Testosterone products (e.g., methyltestosterone, testosterone cypionate, testosterone enanthate, topical gels/solutions) | ||
| PA required for several testosterone presentations (listed as 'PA' in Requirements/Limits) | ||
| Obtain prior authorization before dispensing; document indication and quantity per the formulary entry (QL values where listed) |
| Drug | Requirements/Limits showing ST | Note |
|---|---|---|
| KERENDIA (finerenone) | ||
| Requirements/Limits = QL (30 tablets/30 days), ST | ||
| Step therapy (ST) is indicated for listed finerenone presentations; prior steps must be satisfied per the Drug List |
| CNS / BH agent examples | Requirements/Limits | Coverage implication |
|---|---|---|
| FETZIMA (levomilnacipran) and FETZIMA titration packs | ||
| Requirements/Limits = BH, ST (behavioral health prior authorization plus step therapy) | ||
| Step therapy must be met before coverage; BH designation indicates behavioral‑health prior authorization and QL apply |
| Starter / kit | Quantity limit or starter restriction | Operational note |
|---|---|---|
| MAYZENT starter pack (siponimod) and MAVENCLAD therapy packs | ||
| Requirements/Limits include starter‑pack QLs (e.g., MAYZENT starter pack noted; MAVENCLAD therapy packs have specific QL per pack) — limited supply during initiation | ||
| Starter packs are quantity‑limited for initiation; subsequent dispensing follows standard QL and PA/SP designations as listed |
Quantity Limits and Maintenance Supply
Site of Care and Specialty Pharmacy Routing
Abbreviations and Key Definitions
Policy Background
Specialty drugs are medications used to treat complex or chronic conditions (examples in the Drug List include agents for hepatitis, hemophilia, multiple sclerosis, rheumatoid arthritis, cystic fibrosis and pulmonary arterial hypertension). These products may be oral, topical, or injectable and often require additional handling, patient support, or specialty pharmacy distribution. Medications administered by a health care professional (in‑office or hospital) may be covered under the medical benefit rather than the pharmacy benefit; check the member’s plan materials to determine the appropriate benefit and any specialty program or prior authorization requirements. The Drug List is maintained by a clinical review committee and is updated periodically; providers should consult bcbsnm.com or MyPrime for the most current listing and coverage rules.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.