Coverage for medications is determined by the Drug List and is subject to the member's specific benefit rules and any special requirements shown on the formulary. In general, coverage applies to drugs that are listed on the BCBSNM Drug List and that meet plan rules; many entries include administrative controls such as Prior Authorization (PA), Quantity Limits (QL) and Specialty Pharmacy (SP) routing which must be satisfied for coverage to be approved. Typical dispensing expectations are a 30‑day supply for most prescriptions and up to a 90‑day supply for maintenance medications where the benefit allows. [[chunk 9]]

The Drug List presents per‑product formulary placement (Drug Tier) and line‑level requirements. When an item is marked with PA the prescriber must submit a prior authorization request and obtain approval before the payer will cover the medication. Entries that include QL specify the maximum permitted quantity and time window (for example, many antiretrovirals and DAAs show QL (30 tablets/30 days)). Products marked SP must be dispensed through specialty pharmacy channels as indicated. Coverage is therefore conditional on meeting those per‑product requirements. [[chunk 36]][[chunk 37]][[chunk 72]]

Examples from the listing illustrate how utilization management is applied at the product level. Selected antiviral and anti‑infective products show QL limits (e.g., BIKTARVY QL (30 tablets/30 days); linezolid suspension QL (600 mL/180 days)). Many oncology and specialty agents are designated PA, QL, SP (for example, Zytiga/abiraterone PA, QL (60 tablets/30 days), SP; alectinib PA, QL (240 capsules/30 days), SP). Biologic and specialty injectables (e.g., benralizumab, mepolizumab) are shown with PA and product‑specific QLs and are managed via specialty pharmacy where indicated. Providers should follow the line‑item Requirements/Limits for each product. [[chunk 54]][[chunk 72]][[chunk 216]]

The Drug List also identifies items that are not covered under typical pharmacy benefits: repackaged medications, non–FDA‑approved drugs, certain compounded medications and some prescription products that have available over‑the‑counter equivalents may be excluded from coverage. Where an entry shows administrative flags only (PA/QL/SP) the document excerpt does not provide full clinical medical‑necessity criteria — those are managed through the payer's PA processes and documentation requirements. Providers should consult plan materials or the PA process to determine the specific clinical documentation required for approval. [[chunk 9]][[chunk 72]][[chunk 108]]

This excerpt of the Drug List does not present explicit exclusion lists naming individual agents that are categorically not covered; instead coverage limitations are expressed by omission from the list or via per‑product administrative designations. For example, formulary rows contain Drug Tier and Requirements/Limits values (PA, QL, SP) rather than standalone exclusion statements. Where a product is absent from the Drug List it is not covered under the pharmacy benefit. Refer to the plan's benefit materials for any additional product or category exclusions (e.g., certain cosmetic or age‑restricted uses). [[chunk 36]][[chunk 37]][[chunk 9]]

Because many entries in this excerpt focus on formulary placement and utilization controls rather than explicit exclusion language, providers should assume that lack of a line‑item on the Drug List or failure to meet listed Requirements/Limits (for example, missing PA or exceeding QL) can result in a coverage denial. Exception and appeals processes are available through the telephone number on the member ID card or the plan's benefit guidance. [[chunk 234]][[chunk 72]]

The document excerpt does not include explicit clinical exclusion criteria tied to medical conditions (for example, diagnoses, prior‑therapy failures or contraindications) for the products shown. Instead, coverage is signaled by inclusion on the Drug List with any administrative controls specified on the same line. Where clinical criteria are required to support a PA, those criteria and the required documentation are managed through the payer's authorization process rather than in the line‑item entries in this excerpt. [[chunk 54]][[chunk 72]][[chunk 163]]

Examples in the listing show how utilization management is applied without listing clinical exclusions: corticosteroid and androgen products include QLs or PA (e.g., prednisolone oral solution QL (900 mL/30 days); Rayos QL (30 tablets/30 days); methyltestosterone PA, QL (600 tablets/30 days)), but the excerpt does not state specific clinical conditions that would exclude coverage. For specialty metabolic and endocrine therapies (e.g., SOMAVERT, TYMLOS, CRENESSITY) the entries show PA, QL and often SP designations; the clinical justification required for PA must be provided when submitting authorization. [[chunk 108]][[chunk 111]][[chunk 152]]

The excerpt emphasizes administrative utilization controls as the primary mechanism governing coverage for listed products: Prior Authorization (PA) is required where noted, Quantity Limits (QL) define permitted dispensing amounts and windows, Specialty Pharmacy (SP) flags require dispensing through specialty channels, and Step Therapy (ST) appears on selected products. Claims that lack required PA or that exceed QL are at risk for denial. Providers must follow the Requirements/Limits column and the payer's PA documentation instructions. [[chunk 72]][[chunk 90]][[chunk 163]]

Many high‑cost, specialty and oncology agents in the listing show combined controls (for example, PA + QL + SP). Representative examples include: abiraterone (Zytiga) — PA, QL (60 tablets/30 days), SP; REPATHA products (evolocumab) — PA with presentation‑specific QLs (e.g., 6 syringes/28 days, 2 cartridges/30 days, 6 pens/28 days); FUROSCIX — PA, QL (8 kits/180 days); enalapril oral solution (Epaned) — PA, QL (1200 mL/30 days). Providers should attach clinical justification per the PA process when requesting exceptions or quantities above the stated QL. [[chunk 72]][[chunk 197]][[chunk 188]][[chunk 182]]

Where a line‑item shows only administrative controls (PA/QL/SP) the document excerpt does not include the underlying clinical necessity rules; those are enforced through the payer's authorization review and supporting documentation requirements. For operational questions or to initiate exception/PA requests, use the contact information on the member ID card or the plan's provider resources. [[chunk 93]][[chunk 111]][[chunk 194]]

Specialty drugs are therapies used to treat complex, often chronic or rare conditions (examples include hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis). They may be oral, topical, or injectable, and high-cost or clinically complex agents are frequently managed through additional processes such as Specialty Pharmacy (SP), site-of-care controls (for drugs administered by a health care professional), and utilization management. The drug list is maintained and updated regularly by a committee of clinicians and pharmacists, and coverage for listed products is based on FDA labeling and recognized evidence-based clinical guidelines; plan-level rules such as Prior Authorization (PA), Quantity Limits (QL), step therapy, and benefit routing determine whether a particular prescription is covered under the member's plan.