CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Programs for Members on the Balanced Biosimilar Drug List

Defines prior authorization programs and which prescription drugs/categories on the payer's Balanced Biosimilar Drug List are subject to prior authorization for BCBSNM members. Affects prescribers and pharmacies submitting requests for drugs listed in this document.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Programs for Members on the Balanced Biosimilar Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests for any drug listed on the Balanced Biosimilar Drug List; include the specific product name, category, and supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug categories or entries shown in this partial extract

20+distinct drug classes referenced

multiplebiologic/biosimilar examples

partialdocument fragment status

Provider Actions and Prior Authorization Requirements

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.

Prior Authorization

Provider Actions and Prior Authorization Requirements

Prior authorization is required for prescription drugs and biologics listed on the Balanced Biosimilar Drug List. Requests for these products must have prior authorization in place before coverage will be approved; submissions without prior authorization may be denied or delayed.

Balanced Biosimilar Prior Authorization: Drugs on the Balanced Biosimilar Drug List require prior authorization before coverage.
Prior authorization required: The listing of drug classes and individual products (e.g., CFTR modulators, GLP-1 agonists, growth hormone, interleukin-5 inhibitors, specialty biologics, hepatitis C DAAs, hemophilia factors, etc.) are subject to prior authorization per BCBSNM pharmacy programs.
Prior authorization requirement and exception process: If a drug is not on the Drug List, members or prescribing providers may request an exception review. As part of an exception review, the request may still need to meet the drug’s prior authorization program criteria before approval.
Documentation of listed product: Prior authorization requests should clearly identify the specific product name (brand and/or generic), indication, and relevant clinical information to link the request to the listed product or category.
Documentation expectation: Providers should be prepared to supply clinical rationale, prior treatment history, relevant diagnoses, and any labs or imaging that support medical necessity for the requested drug.
Supporting documentation for PA requests: For specialty agents and biologics (for example, deferasirox/Jadenu/Exjade, Omnitrope, Zorbtive, Ofev, Esbriet, Hemlibra, hepatitis C DAAs, CFTR modulators, GLP‑1 agonists, growth hormone products, etc.), include prior therapy, dosing, weight/age where applicable, genetic or biomarker test results (if required), and prescriber specialty when submitting a PA.
How to initiate prior auth/exception review: To start a prior authorization or exception review, call the number on the member’s ID card or have the prescribing provider submit a request via bcbsnm.com/provider per BCBSNM processes.
Tiered listing (1 vs 2): The Drug List groups agents into preference tiers (e.g., entries labeled “1” and “2”) that indicate tiered listing or preferred agents within a class; prior authorization rules apply to agents in either tier.
Implied preferences (no explicit step rules in chunks): The listing may imply preferred agents within classes (specific agents are grouped under tier 1 or 2), but explicit step therapy rules are not stated in this section.
Step therapy (no explicit rules here): Although step therapy may apply for some classes, this section does not publish explicit step therapy sequences; providers should consult the applicable PA criteria for any required prior steps.
Possible step therapy or utilization management: Some drugs may be subject to utilization management (including step therapy, quantity limits, or prescriber specialty requirements) as part of the prior authorization criteria; review the specific program criteria when submitting a request.

Step Therapy and Tiering Information

Category	Tier 1 (preferred)	Tier 2 (alternate)
Biologic Immunomodulators	Nexletol; 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	Nexlizet; 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	Zymfentra; Qulipta; Ubrelvy; Zavzpret; Qulipta; Ubrelvy
Continuous Glucose Monitor / Devices	Dexcom G6 CGM System; Dexcom G7 CGM System; Freestyle Libre	Freestyle Libre 2; Freestyle Libre 3
Corticotropin (formerly H.P. Acthar)	Acthar Gel; Cortrophin Gel	Purified Cortrophin Gel
Cannabidiol	Epidiolex; Bylvay	(no Tier 2 product listed in these chunks)
Coagulation Factor VIIa	NovoSeven RT	Sevenfact

Biosimilar and Biologic Groupings

Billing Rule

Reference adalimumab/biosimilar listing for PA

Adalimumab and its biosimilars are listed within the Biologic Immunomodulators category; when billing or requesting PA for adalimumab products, reference the listing and any indicated preferred biosimilar entries.

Billing Rule

Specify Factor VIII product on PA/claim

Multiple factor VIII products and related agents are grouped under the Factor VIII category; include the specific product name from the list when submitting authorization or claims.

Billing Rule

Identify ESA product per listing for PA

Erythropoiesis stimulating agents and grouped ESAs (for example, Aranesp, Epogen, Procrit, Retacrit) are listed together; follow the listing when identifying the agent for prior authorization and billing.

Definitions and Key Terms

Balanced Biosimilar Drug List — definition and provider action

DefinitionA payer-maintained list of biologic and biosimilar drugs and related prescription products that are managed via prior authorization and may include preferred alternatives and tiered entries.

PurposeIdentifies biologic/biosimilar and specialty drugs subject to BCBSNM prior authorization programs.

ScopeGroups products by therapeutic category and lists specific brand and biosimilar agents to guide prior authorization and utilization management.

Action for providersRequests for drugs on this list require prior authorization; include the specific listed product and category when submitting documentation.

Balanced Biosimilar Drug List — grouping and tiering

Grouping methodDrugs are grouped by therapeutic category with numbered tier entries (1 vs 2) to indicate preferred products or tiers (e.g., Biologic Immunomodulators 1 vs 2; CGRP 1 vs 2).

Examples of grouped categoriesBiologic Immunomodulators; Calcitonin Gene-Related Peptide (CGRP) agents; Coagulation Factor VIIa; Combination NSAIDs.

Listed products within groupsEntries enumerate specific brands and biosimilars (e.g., multiple adalimumab biosimilars, Actemra SC, Aimovig, Ajovy, Emgality, Nurtec ODT).

Implication for coverageProducts listed within the same group may reflect internal preferences or sequencing that inform prior authorization decisions, though explicit step-therapy rules are not provided in these chunks.

Interstitial Lung Disease (formerly IPF) — definition and listed therapies

DefinitionA group of lung disorders historically referenced as Idiopathic Pulmonary Fibrosis (IPF); the document refers to this as Interstitial Lung Disease (formerly IPF).

Antifibrotic therapies listedPirfenidone (Esbriet) and nintedanib (Ofev) are enumerated in the Interstitial Lung Disease / IPF category.

Related specialty agentsThe chunks also reference other agents in the context of ILD/IPF listings (e.g., Fasenra mentioned alongside Esbriet in the IPF context).

Provider actionPrior authorization is required for listed ILD/IPF therapies; include the specific agent (Esbriet or Ofev) and indication when requesting authorization.

Balanced Biosimilar Drug List — program note and exception process

DefinitionA payer-managed list of biologic and biosimilar medications and specialty drugs that are governed by prior authorization and utilization management programs for BCBSNM members.

Program noteThese programs are subject to change and additional drugs may be added; the list provides examples of categories and specific medications included in prior authorization programs.

Exception processIf a drug is not on the Drug List, a member or prescribing provider can request an exception review; meeting the drug's prior authorization program criteria may be required as part of that review.

ContactTo start an exception or prior authorization review, call the number on the member ID card or ask the doctor to visit bcbsnm.com/provider.

Background and Scope

This extract is a partial, index-style listing of prescription drugs, biologics and biosimilars grouped by therapeutic category that are managed under Blue Cross Blue Shield of New Mexico’s pharmacy prior authorization programs. It enumerates both brand and biosimilar product names and shows category-level groupings, including multiple numbered entries (e.g., “1” and “2”) that indicate internal preference tiers or grouped alternatives, but it does not contain complete clinical criteria or step-failure rules within these chunks.

Providers and pharmacies should treat the document as a catalogue of products subject to prior authorization and utilization management; for any specific drug the payer may require submission of supporting documentation that identifies the listed product and its clinical indication, and requests for products not shown may be eligible for an exception review via the phone number on the member ID card or the BCBSNM provider portal.