CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

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

List of drug categories and specific drugs assigned to Performance Select Biosimilar Drug List prior authorization programs, showing mapping/groupings (multiple numbered tiers) and alternative dosage form notes. This part contains a fragmented enumerated mapping of categories to specific products.

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 TypeInformational / Clarification (enumerated drug mappings)

Effective Date

Next Review Date

Key ActionDrugs listed under the Performance Select Biosimilar Drug List are governed by prior authorization programs; providers must follow the payer's PA process for listed products.

POLICY UPDATE CHANGES

This document is a mapping/list of categories to specific drugs for the Performance Select Biosimilar Drug List.

This file (part 2 of 3) lists numerous drugs, therapeutic categories, and mappings (e.g., branded to biosimilar/alternative) relevant to the Performance Select Biosimilar Drug List prior authorization program.

Part 3 provides additional drug name mappings and category examples included in the Performance Select Biosimilar Drug List.

~120Distinct drug/product mentions in part

multipleCategories represented

Document purpose and scope

This part (part 2 of 3) of the multi-part Performance Select Biosimilar Drug List provides a fragmented, enumerated mapping of therapeutic categories to specific products (including brand-to-biosimilar/alternative mappings and alternative dosage form notes) intended for use in the payer's prior authorization program. Examples in this part include categories such as Acute Migraine, Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis), Calcitonin Gene-Related Peptide (CGRP), ATTR Amyloidosis, Continuous Glucose Monitor, Cystic Fibrosis Transmembrane Conductance Regulator (CFTR), and many others with lists of associated drugs. Full clinical prior authorization criteria, billing codes/NDCs, and effective dates are not provided here and appear in other policy parts.

Key facts — Performance Select Biosimilar Drug List (Part 1)

PayerBlue Cross Blue Shield - New Mexico

Policy titlePerformance Select Biosimilar Drug List - Prior Authorization Programs (Part 1)

Policy numberN/A

Effective date

StatusCURRENT

Scope summaryList of drug categories and specific drugs assigned to Performance Select Biosimilar Drug List prior authorization programs; contains fragmented enumerated mappings of categories to specific products and alternative dosage form notes.

Drug and therapeutic category mappings in this part

Drug / Category mappings present in this partmixed

Acute Migraine	Reyvow; Trudhesa; Migranal
Agamree Emflaza (formerly Emflaza)	Agamree; Emflaza
Alhemo	Alhemo
Alternative Dosage Form	Carafate/sucralfate; Lyvispah/baclofen granules; Meloxicam suspension; Naprosyn/naproxen suspension; Nexium granules; Norliqva/amlodipine oral solution; Ozobax solution/baclofen; Qbrelis solution; Sotylize solution; Sprix/ketorolac nasal spray; Tiglutik suspension
Arikayce	Arikayce
ATTR Amyloidosis	Attruby; Tegsedi; Vyndaqel; Vyndamax; Wainua
Bempedoic Acid	Nexletol; Nexlizet
Biologic Immunomodulators (Rheumatoid Arthritis/Psoriasis)	Abrilada; Actemra subcutaneous; Adalimumab-aacf; Adalimumab-aaty; Adalimumab-adbm; Adalimumab-ryvk; Amjevita; Bimzelx; Cimzia; Cosentyx; Cyltezo; Enbrel; Entyvio; Hadlima; Hulio; Humira; Humira Starter Kit; Hyrimoz; Omvoh; Orencia subcutaneous; Otulfi; Pyzchiva; Rinvoq; Selarsdi; Siliq; Simlandi; Simponi; Skyrizi; Sotyktu; Stelara; Steqeyma; Taltz; Tremfya; Tyenne
Calcitonin Gene-Related Peptide (CGRP)	Aimovig; Ajovy; Emgality; Nurtec ODT; Olumiant; Zymfentra; Qulipta; Ubrelvy; Zavzpret
Camzyos	Camzyos; Zavzpret

1–10 of 46

1/5

Note: this document is a continuation and contains fragmented and sometimes repetitive category-to-drug entries; the full prior authorization (PA) criteria, NDCs/codes, and effective dates for listed products are maintained in other parts of the policy and must be consulted for authorization decisions.

What providers must do

Prior Authorization

Prior authorization required per Performance Select Biosimilar Drug List

Drugs listed under the Performance Select Biosimilar Drug List are governed by prior authorization programs; providers must follow the payer's PA process for listed products.

Prior Authorization

Prior authorization applies to drugs on Performance Select Biosimilar Drug List

Members/providers must follow prior authorization programs for drugs and therapeutic categories listed on the Performance Select Biosimilar Drug List; this document is a part of that listing and maps specific product names and equivalents that may be subject to PA.

Document change notes

clarified

This document is a mapping/list of categories to specific drugs for the Performance Select Biosimilar Drug List. It enumerates numerous therapeutic categories and specific product names intended for the payer's prior authorization program, presented as fragmented enumerations without full clinical criteria or effective dates in this part.

clarified

This file (part 2 of 3) lists numerous drugs, therapeutic categories, and mappings (for example, branded to biosimilar/alternative) relevant to the Performance Select Biosimilar Drug List prior authorization program; it continues the drug list and does not provide explicit clinical criteria or effective dates in this part.

clarified