CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Specialty Drug Management List (specialty medications coverage)

Defines the list of medications identified as specialty drugs by Blue Cross and Blue Shield of New Mexico and describes how coverage is provided under pharmacy or medical benefits; intended for providers and members to determine whether drugs are managed as specialty medications and where to seek benefit information.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySpecialty Drug Management List (specialty medications coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders should use BCBSNM request forms at bcbsnm.com/provider or call the number on the member ID card to request prior authorization when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks in this partial extract

multiplespecialty drugs listed (partial list shown)

10/01/2025date printed on pages

multilinguallanguage assistance available

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

The listing of a drug on the Specialty Drug Management List does not guarantee coverage. Providers and members should verify benefits for each patient because appearance on this list is informational and not an authorization of payment or indication of coverage under a specific member’s plan. If you have questions about coverage, call the number on the member’s ID card.

This excerpt is a listing of medications identified as specialty drugs and does not state explicit coverage exclusions. The Specialty Drug Management List is subject to change without notice; product names remain the property of their respective owners and inclusion on these pages is not exhaustive. Always confirm current benefit terms with the payer or by calling the number on the member ID card.

Provider Actions & Authorization

Prior Authorization

Prior Authorization / Provider Actions

This specialty drug listing is informational but includes multiple provider-action notes: prior authorization may be required for some drugs (not all specific PA rules are listed here), and no explicit authorization/denial triggers or denial criteria are provided in the extract. Providers should use the payer's prior authorization request forms or call the number on the member ID card for benefit-specific requirements. Members may be required to fill prescriptions at an in-network specialty pharmacy to obtain full benefits.

Prior authorization — not specified in this listing (some products may require PA per member plan).
Specialty drug listing — this section lists specialty drugs and routes but does not state specific PA criteria or affected billing codes.
No explicit authorization or denial triggers provided in this excerpt.
No explicit prior authorization denial triggers provided here.
How to request prior authorization: providers can find request forms at bcbsnm.com/provider or call the number on the member/patient ID card for benefit-specific requirements.

Note

Prime Therapeutics / Specialty Pharmacy Relationship

The document includes administrative statements about Prime Therapeutics: Prime Therapeutics LLC is identified as a separate company contracted by Blue Cross and Blue Shield of New Mexico to provide pharmacy solutions. It also notes that Blue Cross and Blue Shield of New Mexico, along with several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. The relationship with specialty pharmacies is described as independent contractors.

Prime Therapeutics LLC is a separate contracted pharmacy solutions vendor for BCBSNM.
BCBSNM and some independent Blue Plans have an ownership interest in Prime Therapeutics.
Specialty pharmacies are independent contractors relative to BCBSNM.

Step Therapy

This listing does not describe any step therapy rules or step edits. If step therapy applies for a specific drug under a member's plan, providers should confirm requirements via the payer's provider portal or by calling the member services number on the ID card.

No step therapy rules provided in this specialty drug list.

Definitions & Keys

Specialty medications definition

DefinitionSpecialty medications are drugs prescribed for complex and/or chronic conditions that may have special handling and/or storage needs (examples: multiple sclerosis, hepatitis C, rheumatoid arthritis).

Coverage pathFDA‑approved self‑administered specialty medications are often covered under the pharmacy benefit; those approved for administration by a health care professional are often covered under the medical benefit.

Dual listingSome medications may appear under both pharmacy and medical benefits depending on formulation and route.

Pharmacy vs Medical benefit

Pharmacy vs. MedicalSelf‑administered specialty medications are typically covered under the pharmacy benefit; professionally administered specialty medications are typically covered under the medical benefit.

Possible dual coverageSome drugs on the Specialty Drug Management List may be covered by either the pharmacy or medical benefit and can appear in both sections.

Prior approval & site requirementsBased on plan terms, prior approval and use of an in‑network specialty pharmacy may be required to receive full benefits for certain drugs.

Route of Administration key mapping

IVIntravenous

IXIntraarticular

IZIntravitreal

OPOphthalmic

OROral

SCSubcutaneous

Route of Administration key

IVIntravenous

IXIntraarticular

IZIntravitreal

OPOphthalmic

OROral

SCSubcutaneous

Route of Administration key mapping

IVIntravenous

IXIntraarticular

IZIntravitreal

OPOphthalmic

OROral

SCSubcutaneous

Prime Therapeutics / specialty pharmacy relationship

Contracted vendorPrime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of New Mexico to provide pharmacy solutions.

Independent contractorsThe relationship between BCBSNM and specialty pharmacies is that of independent contractors.

Ownership interestBCBSNM and several independent Blue Plans have an ownership interest in Prime Therapeutics.

Step Therapy & Specialty Pharmacy Rules

Situation	Guidance
Members using oral oncology or hemophilia specialty drugs
May have other specified in-network specialty pharmacy options; call the number on the member ID card to locate an in-network specialty pharmacy
Prior approval requirement
You may need approval before these drugs can be considered for coverage; providers can find request forms at bcbsnm.com/provider or call the phone number on the member ID card
Site-of-fill requirement
Based on your benefit plan, you may need to fill prescriptions at an in-network specialty pharmacy to receive full benefits

Background

Specialty medications are drugs that our plans identify as being used to treat complex and/or chronic conditions such as multiple sclerosis, hepatitis C, and rheumatoid arthritis. These drugs may require special handling and storage and can be provided under either the pharmacy benefit (for FDA‑approved self‑administered products) or the medical benefit (for products administered by a health care professional). Some products may appear in both sections depending on formulation and route of administration.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySpecialty Drug Management List (specialty medications coverage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders should use BCBSNM request forms at bcbsnm.com/provider or call the number on the member ID card to request prior authorization when required.

SourceLink

On This Page

OpenPayer

Specialty Drug Management List (specialty medications coverage)

Coverage Criteria

Provider Actions & Authorization

Definitions & Keys

Step Therapy & Specialty Pharmacy Rules

Site of Care Considerations

Background