2026 Drug List (pharmacy drug formulary) - Coverage Criteria
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The document lists covered prescription and specialty drugs, coverage rules (e.g., tiers, prior authorization, step therapy, quantity limits), and member/provider guidance for Blue Cross Blue Shield of New Mexico pharmacy benefits; it is intended for members, prescribers, and pharmacists.
No material clinical or coverage changes in this revision.
Pharmacy Coverage Criteria
Pharmacy Coverage Overview
Covered drugs are those listed on the Drug List and are governed by plan-specific rules; drugs not on the list are not covered.
From general introduction and coverage considerations
Special Requirements column annotations (PA, ST, QL, AC, BH, NM)
Per-product coverage flags
Coverage and utilization controls are specified per drug entry using Requirements/Limits flags (PA, QL, SP, AC, NM).
No patient-level clinical criteria are provided in these chunks; only per-product controls are listed.
General coverage controls
Coverage and utilization management for listed drugs are governed by the following plan-level controls:
Applies per individual drug entry as specified in the Requirements/Limits field.
Covered with product-specific PA/QL/SP
Coverage entries with utilization controls are subject to specified PA and QL as listed per product.
Applies per individual product entries in this segment.
Per-drug coverage conditions
Drugs are listed with coverage-related flags; coverage requires meeting the listed flags per line (e.g., PA, QL, BH, SP).
Providers must consult the specific line item for exact QL or PA requirements.
Drugs must be listed on the BCBSNM Drug List to be covered. Drugs not shown on the list are not covered; repackaged versions, compounded medications (coverage depends on the member's plan), and non–FDA‑approved drugs are explicitly identified as not covered in the Coverage Considerations section. Providers and members should verify coverage and up‑to‑date formulary placement via bcbsnm.com, MyPrime.com, or the phone number on the member ID card.
Within the provided extract there are no additional explicit exclusions stated beyond the general coverage limitations; the drug lines in this segment report tier and Requirements/Limits annotations without separate exclusion language.
Several vaccine product lines are annotated with NM (Not Medically Necessary) alongside administrative codes (AC) in the Requirements/Limits field. These NM/AC annotations indicate that specific formulations, age groups, or indications may be considered not medically necessary or subject to administrative conditions
Some drug entries are labeled as Non‑Preferred (np / NP) or otherwise tiered as non‑preferred. Where present, these annotations affect formulary status and member cost share; entries without PA or QL values are still shown but may be non‑preferred by tier. Providers should follow the Requirements/Limits flags (PA, QL, SP, AC, NM) shown on each product line when submitting claims or prior authorization requests.
The lines in this segment provide drug name, tier and Requirements/Limits fields but do not include standalone clinical exclusion statements. Coverage is governed by the per‑product Requirements/Limits codes (e.g., PA, QL, SP, AC) shown for each line item.
No explicit exclusion statements are present in the referenced chunks of the extract. The document in this area lists formulary lines and their tier/Requirements/Limits annotations without additional exclusion narrative.
Certain product lines in the drug list are explicitly annotated with NM (Not Medically Necessary) for particular formulations — for example, multiple azithromycin and erythromycin entries in the macrolide section carry an NM flag (often paired with quantity limits). These NM annotations indicate that those specific formulations or uses are considered not medically necessary per the formulary listing and may be denied when billed for excluded indications.
In the chunks referenced there are no explicit 'Not Medically Necessary' determinations beyond the previously noted examples; the entries here primarily present drug lines with tier and Requirements/Limits annotations.
Multiple vaccine and biologic lines (e.g., COMIRNATY, SPIKEVAX, NUVAXOVID, ENGERIX‑B, PREVNAR 20) are annotated with AC and in some cases NM. Entries marked NM (for specific formulations, age ranges, or indications) indicate those product lines are regarded as not medically necessary in certain contexts and therefore excluded for those uses; providers should check the specific vaccine line and member benefit to determine allowable indications.
No explicit Not Medically Necessary determinations are stated in these chunks. The extract largely lists formulary items and their flags; specific NM decisions appear where annotated on individual product lines elsewhere in the list.
Drug List Coding and Tiers
| N/A | NDCs, CPT, or HCPCS codes are not present in these chunks; entries are drug name, strength, tier, and Requirements/Limits. |
| NP | Drug Tier = NP (non-preferred or non-preferred specialty designation as listed) |
| P | Drug Tier = P (preferred) |
| AC | Requirements/Limits = AC (administrative condition / authorization code) |
| NM | Requirements/Limits = NM (not medically necessary for some indications) |
| PA | Requirements/Limits = PA (prior authorization required) |
| QL | Requirements/Limits = QL (quantity limit with specifics following) |
| SP | Requirements/Limits = SP (specialty) |
| NDCs not provided | Document lists drug names and formulations but does not list NDC or CPT/HCPCS/ICD-10 codes in these chunks. |
Provider Requirements and Authorization Actions
Prior Authorization Requirement
Prior Authorization Required — Some medications listed in this formulary require prior authorization (PA). When a drug’s Requirements/Limits field includes “PA,” the prescriber must submit a prior authorization request and obtain approval before coverage will be allowed. Claims for PA‑listed products may be denied if PA is not obtained.
- PA indicated in the Requirements/Limits column for many products (examples: EPCLUSA, HARVONI, SOVALDI, VOSEVI, VOSEVI).
- Lack of PA may result in claim denial or delay.
Prior authorization required for selected specialty/high‑cost anti‑infectives
Selected specialty or high‑cost anti‑infective agents and inhaled antibiotics require prior authorization and may have quantity limits and specialty pharmacy (SP) dispensing requirements. Examples include ARIKAYCE, TOBI formulations, KITABIS PAK, posaconazole formulations, and certain hepatitis C agents.
- ARIKAYCE — PA, QL (28 vials/28 days), SP.
- TOBI PODHALER / TOBRAMYCIN nebu soln — PA, QL, SP (examples: 280 mL/56 days or 224 capsules/56 days).
- Posaconazole (NOXAFIL) formulations — PA for select formulations; some oral solutions have QL (1200 mL/30 days).
Prior authorization required for listed PA drugs
Many individual branded or specialty drugs in the formulary are annotated with PA in the Requirements/Limits column; prescribers must submit PA requests per the plan’s submission process. Examples span oncology, specialty biologics, cardiometabolic agents, and other high‑cost brands.
- Examples: numerous oncology/specialty agents (see oncology section) list PA + QL + SP flags.
- Branded agents requiring PA include MYFEMBREE, ORIAHNN, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY, and others.
Specialty program requirement for Palforzia
Palforzia (peanut allergen powder) product lines are designated SP and have level‑specific packaging (initial dose, level packs, maintenance, titration). Specialty program workflows and specialty dispensing are likely required; prescribers should follow PA/Specialty pharmacy procedures when requesting coverage.
- Palforzia levels and packs annotated with SP (specialty) — initial dose, levels 0–11, maintenance and titration packets.
- Specialty authorization/workflow required for SP products; contact the number on the member ID card for PA or specialty routing.
Prior authorization required for many oncology/specialty drugs
Prior authorization is required for many oncology and other specialty drugs. These products commonly carry PA plus quantity limits (QL) and SP flags; providers must submit documentation supporting diagnosis, prior therapies, dosing and intended duration to justify medical necessity.
- Oncology examples with PA/QL/SP: ALUNBRIG, AYVAKIT, BALVERSA, BOSULIF, CABOMETYX, IBRANCE, IMBRUVICA, KISQALI, LYNPARZA, many others.
- Submit PA with clinical rationale, relevant pathology/genetic tests, and prior treatment history when applicable.
Prior authorization required for selected branded agents
Selected high‑cost branded agents require prior authorization prior to coverage. Examples in the formulary include MOUNJARO (tirzepatide), OZEMPIC (semaglutide), RYBELSUS, TRULICITY, and other GLP‑1 agonists and weight‑management or specialty endocrinology agents.
- MOUNJARO — PA, QL (1–4 pens per period depending on strength).
- OZEMPIC — PA, QL (1 pen/28 days).
- RYBELSUS — PA, QL (30 tablets/30–180 days depending on strength).
Prior authorization required for selected agents
Prior authorization is required for multiple GLP‑1 agonists and other specialty agents; submit PA requests per plan procedures to avoid denials.
- MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY and other GLP‑1 agents are annotated PA and have QL entries.
- Providers should include indication, prior therapies tried, and dosing plan in PA submissions.
PA for specialty/high‑cost drugs
Many specialty or high‑cost products listed include PA and QL designations. For SP‑flagged products, specialty pharmacy dispensing and associated prior authorization workflows typically apply.
- SP = specialty; claims may be routed to specialty pharmacies. Examples: EPCLUSA, HARVONI, SOVALDI, many oncology agents.
- Ensure specialty pharmacy requirements are met (shipping, handling, administration settings) when submitting PA.
Prior authorization and quantity limits
Prior authorization and quantity limits govern coverage — when a product lists PA and/or QL in Requirements/Limits, prescribers must obtain PA and adhere to the listed quantity limits. Exceeding QL or lacking PA may lead to denial or reduced benefits.
- Quantity limit examples: QL 1 pen/28 days (OZEMPIC), QL 4 pens/28 days or 4 pens/180 days (MOUNJARO depending on strength), QL 6 syringes/28 days (REPATHA).
- If dosing above the QL is medically necessary, include supporting documentation in the PA request.
PA required for listed specialty/high‑cost drugs
Prior authorization is required for many listed specialty/high‑cost products across the formulary; check each drug entry’s Requirements/Limits for PA and QL notations and follow the specified submission process.
- Examples: TREMFYA (PA, QL 1 syringe/28 days), VOWST (PA, QL 12 capsules/12 months), ZYMFENTRA products (PA, QL 2 pens/28 days).
- Follow SP routing and PA submission steps for these products.
NM flags may trigger denial
NM (Not Medically Necessary) flags denote utilization constraints and may indicate that the product will be denied for the listed indication. Entries marked NM should trigger review of coverage criteria and, where appropriate, a PA or exception request with supporting clinical justification.
- Examples: select azithromycin formulations annotated NM, many HIV/HCV products show NM for certain formulations.
- NM annotation may indicate that the product is not covered for the billed indication and can trigger denial if billed without approved exception.
Prior authorization required for certain hepatitis agents
Certain hepatitis C agents and other antiviral products are PA‑ and SP‑flagged due to high cost and specialized treatment regimens. Examples include EPCLUSA, HARVONI, SOVALDI, VOSEVI and related pellet or pack formulations — PA and QL apply.
- EPCLUSA, HARVONI, SOVALDI, VOSEVI — PA, QL (typically 28 or 30 tablets/packs), SP.
- PA documentation should include genotype, fibrosis staging, and prior treatment history when relevant.
NM annotation may indicate denial risk
Some vaccine and biological entries include NM annotations for certain formulations or age indications; NM may result in denial when billed for non‑covered uses. Verify indication and member eligibility prior to claim submission.
- Example: certain COMIRNATY entries show AC, NM depending on formulation/age group.
- Confirm coverage for the specific vaccine formulation and member age; request exception if clinically indicated.
PA required for many oncology drugs
PA is required for many oncology drugs listed in the formulary. Claims for these agents may be denied if PA is not obtained. Providers should proactively submit PA requests with full clinical documentation.
- Numerous oncology agents list PA + QL + SP (examples: ALUNBRIG, AYVAKIT, BOSULIF, IBRANCE, IMBRUVICA).
- Obtain PA prior to dispensing to avoid denials or member financial liability.
PA required for MYFEMBREE
MYFEMBREE requires prior authorization and has a quantity limit of 30 tablets per 30 days. Submit PA with clinical rationale and relevant diagnostic information.
- MYFEMBREE — PA, QL (30 tablets/30 days).
PA required for ORIAHNN
ORIAHNN requires prior authorization and has a quantity limit (56 capsules/28 days). Ensure PA is obtained and the PA submission includes relevant clinical documentation.
- ORIAHNN — PA, QL (56 capsules/28 days).
PA required for MOUNJARO
MOUNJARO (tirzepatide) is annotated with PA and has specific quantity limits depending on formulation: some strengths list QL (4 pens/28 days) or QL (4 pens/180 days) for starter strengths. Obtain PA before dispensing.
- MOUNJARO — PA, QL (4 pens/28 days for standard strengths; 4 pens/180 days for starter 2.5 mg strength).
PA required for OZEMPIC
OZEMPIC (semaglutide) requires prior authorization and has a quantity limit of 1 pen per 28 days. Ensure PA approval prior to dispensing and include indication and prior therapy info as needed.
- OZEMPIC — PA, QL (1 pen/28 days).
Lack of prior authorization for products listed with 'PA' may trigger coverage denial
Absence of required prior authorization for products labeled PA may lead to claim denial. Providers should check each drug’s Requirements/Limits and obtain PA prior to dispensing to avoid member liability.
- Review the Requirements/Limits column for PA and QL notations before prescribing/dispensing.
- If PA denial occurs, consider step therapy or exception processes as applicable.
Required submission information and documentation to support PA
Providers must submit PA requests and supporting documentation per the Requirements/Limits listed for each product. Documentation should support dose, indication, prior therapies, and expected duration of therapy to demonstrate medical necessity.
- Required submission information often includes diagnosis, prior treatment history, lab/pathology/genotype data, and proposed dosing schedule.
- For expedited clinical situations, an expedited review may be requested (see exception process and contact number on the member ID card).
Document Requirements/Limits
Drug list entries include coded Requirements/Limits such as PA (prior authorization), QL (quantity limits), SP (specialty), AC (administrative code), BH (behavioral health), ST (step therapy), and NM (not medically necessary). Adhere to the codes listed for each product when submitting requests.
- Examples of quantity limits: QL 1 pen/28 days, QL 4 pens/28 days, QL 60 tablets/30 days, QL 1200 mls/30 days.
- Follow submission instructions for the specific Requirement/Limits codes shown.
Quantity limits must be adhered to when submitting
Some products have explicit quantity limits (QL) which must be respected when submitting PA or when dispensing. If higher quantities are clinically necessary, include justification in the PA request.
- Examples: QL 1 pen/28 days (OZEMPIC), QL 4 pens/28 days or 4 pens/180 days (MOUNJARO), QL 28 vials/28 days (ARIKAYCE).
- Requests exceeding QL without approved PA/override may be denied or result in member financial responsibility.
PA documentation note and support for PA requests
Some PA entries include product‑specific PA documentation notes — for example, liquid formulations, oral solutions, and certain specialty products require PA plus QL and product‑specific documentation (e.g., enalapril oral solution, droxidopa strengths, FUROSCIX). Ensure PA submissions reference the exact formulation and strength.
- Enalapril oral solution (Epaned) — PA, QL (1200 mL/30 days).
- FUROSCIX — PA, QL (8 kits/180 days).
- Droxidopa (Northera) — PA, QL varies by strength (100 mg QL 450 caps/30 days; 200/300 mg QL 180 caps/30 days).
- REPATHA — PA, QL (6 syringes or 6 pens/28 days).
Submit according to listed Requirements/Limits
Submit prior authorization requests according to the Requirements/Limits specified on each formulary entry. Include all requested documentation to support medical necessity; specialty products often require SP routing and additional specialty pharmacy forms.
- Follow the payer’s PA submission process (contact number on member ID card or payer portal).
- Include indication, prior therapy history, labs/genetic tests, and dosing plan with the PA request.
Step therapy may require trial of first‑line medications
Step Therapy (ST) programs may require trial of first‑line medications before certain agents are covered. For products carrying an ST flag, prescribers can request a step therapy exception with supporting clinical rationale. Not all segments list ST; where ST applies it will be indicated in the Requirements/Limits column.
- Example BH/ST entries: FETZIMA, FLUOXETINE DR, FANAPT titration packs show BH and ST flags.
- Some oncology or specialty agents imply step sequences though explicit ST may not be listed in every segment.
Step therapy absence note
Step therapy is not specified for all listed products in this segment — many entries focus on PA, QL, SP, NM and BH flags. Where ST is not shown, step therapy requirements may not apply.
- Absence of an ST flag in the Requirements/Limits column generally indicates no step therapy requirement is specified in this segment.
- If in doubt, contact the payer or call the number on the member’s ID card for confirmation.
Some agents are marked SP (specialty) or require specialty pharmacy dispensing
Some agents are specifically designated SP (specialty). Specialty designation often requires specialty pharmacy dispensing, specific PA workflows, and adherence to QL and handling requirements.
- SP‑flagged products include many oncology agents, biologics, and specialty injectables (examples throughout this formulary).
- Specialty pharmacies may manage distribution, prior authorizations, and patient support programs.
Providers or members can request Drug List or step therapy exceptions by calling the number on the ID card
Where coverage decisions are needed (exceptions, step therapy or PA), providers or members can request reviews by calling the number on the member’s ID card. Expedited review is available for urgent clinical needs.
- Standard PA/exception decisions: notice within three business days after receipt of the request.
- Expedited requests for urgent conditions: decision within 24 hours after receipt.
Behavioral health medication controls
Behavioral health (BH) medications carry BH program controls and in some cases PA, QL or ST requirements. Failure to comply with BH program authorization may result in denial.
- Examples: many antidepressants, antipsychotics, and BH agents are flagged BH and may include QL and ST.
- Follow BH program submission pathways and include relevant clinical history in PA/BH requests.
Denial triggers: missing PA or QL exceedance
Denial Triggers — Claims may be denied if required prior authorization is missing, if the dispensed quantity exceeds the specified Quantity Limit (QL), or if the drug is billed for an indication marked NM without an approved exception. Providers should verify PA/QL/NM status before dispensing.
- Missing PA for PA‑flagged products can lead to denial.
- Exceeding QL without an approved override may result in denial or full member financial responsibility.
- Drugs marked NM for the billed indication may be denied absent an approved exception.
Definitions and Code Flags
Initial Dispensing and Therapy Criteria
Initial dispensing limits
Quantity limits and prior authorization requirements for initial dispensing where specified.
Prescribers must request quantities consistent with QL and obtain PA when indicated.
Initial therapy limits
See product line for exact QL/PA.
Initial therapy flags
Examples of products requiring prior authorization and specialty handling.
Prior authorization documentation and specialty pharmacy routing required per plan.
Step Therapy / Fail-First Rules
| Step therapy summary | Notes / provider actions |
|---|---|
| Step therapy (ST) is identified on the Drug List with an 'ST' notation when a plan-level step requirement applies. | Providers or members may request a step therapy exception by calling the number on the member ID card; BCBSNM will notify the requester of a decision within three business days, or within 24 hours for expedited requests when clinically urgent. |
| Observed entry | Step therapy details present? |
|---|---|
| Multiple drug lines in the antiviral/antiretroviral sections (e.g., EPCLUSA, GENVOYA) and various systemic agents shown in these chunks. | No explicit multi-step sequences or fail‑first algorithms are listed in these chunks; entries show per-product flags (PA, QL, SP, NM) only. |
| Product | Step/pack implication |
|---|---|
| Palforzia (LEVEL 0–LEVEL 11 dosing packs) | Each level/pack is annotated SP and listed as LEVEL 0–11 packaging; specialty designation and levelized packs imply adherence to packaging/step dosing levels for therapy initiation and maintenance. |
| Chunk / product group | Step therapy specified? |
|---|---|
| Corticosteroids and related generics (examples shown in chunk) | No step therapy entries appear in this excerpt; step therapy not specified for the listed products in these chunks. |
| Product | Step therapy specified? |
|---|---|
| MOUNJARO (tirzepatide) and other antidiabetic GLP-1/GIP agents (examples: MOUNJARO, OZEMPIC) | No explicit step‑therapy sequences are provided here; entries list PA and QL but not step therapy algorithms in these chunks. |
| Products noted | Authorization requirement |
|---|---|
| Selected high-cost agents and GLP‑1/GIP products (examples listed: MOUNJARO, OZEMPIC, ACTHAR, CRENESSITY) | These products are annotated with 'PA' (prior authorization) in the Requirements/Limits field — prior authorization is required before coverage is approved. |
| Product | Plan flag |
|---|---|
| KERENDIA | Flagged with 'ST' in the formulary indicating a step therapy requirement applies per the plan. |
| Products | Authorization / step therapy |
|---|---|
| NEXLETOL (bempedoic acid) / NEXLIZET (bempedoic acid-ezetimibe) | Both entries show 'PA' and 'QL (30 tablets/30 days)'; no explicit step-therapy sequence is described in these chunks. |
| Chunk / product examples | Step therapy status |
|---|---|
| Various antiviral, vaccine, and generic product lines shown across these segments | No explicit step therapy requirements appear in these segments; other parts of the full document may contain step edits not present here. |
| Products with ST flag | Implication |
|---|---|
| Examples: FETZIMA titration pack, FLUOXETINE DR, FANAPT (and titration packs), CLOZAPINE ODT, TRINTELLIX (examples from BH/antidepressant sections) | Where 'ST' is indicated alongside these products (often with BH designation), step therapy requirements apply — prior trials of preferred agents or behavioral‑health program rules may be required per plan. |
| Chunk / product group | Step therapy details present? |
|---|---|
| Neurology / multiple neurologic and BH product listings (examples: dimethyl fumarate, fingolimod, glatiramer acetate) and other specialty lines | Step therapy specifics are not included in these chunks; listed requirements focus on PA, QL, SP and BH flags rather than explicit step algorithms. |
Quantity Limits and Maintenance Supply Guidance
Site-of-Care and Specialty Pharmacy
Background
Specialty drugs are used to treat complex, often chronic conditions (for example, hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis). They may be self‑administered (e.g., auto‑injector or pen) or administered in a health‑care setting; medications requiring provider administration may be billed to the medical benefit rather than the pharmacy benefit. The formulary classifies medications by therapeutic class and by FDA‑approved primary indication and includes utilization controls (PA, QL, SP) on many specialty products.
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