CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

BCBSNM 2025 Drug List (partial)

Pharmacy benefit drug list from Blue Cross and Blue Shield of New Mexico outlining covered drugs, tiers, special requirements (PA, ST, QL, AC, SP), dispensing limits, specialty pharmacy process (Accredo), exception and appeal processes, and non-coverage categories. This brief covers the portion of the formulary document provided (therapeutic class listing and many anti-infective agents).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyBCBSNM 2025 Drug List (partial)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when 'PA' is indicated and follow specialty pharmacy (Accredo) routing when required.

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this brief (has_material_change=false).

manyDrugs listed in excerpt

multipleMedications with PA/QL/SP flags

1Specialty pharmacy (Accredo)

ManyProducts with QL

severalSpecialty (SP) products

Coverage is limited to the drugs listed on this drug list; only drugs shown on this drug list are covered, and placement on a formulary tier determines coverage rules and the member’s cost‑sharing. Tiers (e.g., Preferred/Non‑Preferred and specialty tiers) set how much a member pays. Some listed drugs carry special requirements — for example PA (prior authorization), ST (step therapy), QL (quantity/dispensing limits) or SP (specialty) — which affect coverage and may require provider action before the drug is covered. Drugs that need a health care provider to administer may be covered under the medical benefit rather than the pharmacy benefit. Non‑listed drugs, non‑FDA‑approved drugs, repackaged versions, and certain compounded medications are generally not covered unless otherwise noted in plan materials.

General Coverage/Requirements for Drugs on the Drug List

Coverage is determined by tier placement and may be subject to special requirements; drugs not listed are not covered:

General Coverage/Requirements: Only drugs shown on this drug list are covered; drugs not on the list are not covered

Document: All covered drugs are those listed on the Drug List; see member ID card/provider portals for current list

Prior Authorization (PA): Some drugs require prior authorization (marked 'PA' under Special Requirements)

Prior Authorization required when PA noted next to medication in Special Requirements

Step Therapy (ST): Some drugs are subject to step therapy (marked 'ST' under Special Requirements)

Step therapy programs require trying first-line medications before coverage for others; exceptions may be requested

Quantity/Dispensing Limits (QL/DL): Some drugs have dispensing/quantity limits (marked 'QL' or 'DL' under Special Requirements)

Limits include maximum quantity per prescription or timeframe (examples and thresholds shown in product-level block); claims exceeding QL may be denied or member responsible

ACA preventive (AC): Some drugs are ACA preventive (marked 'AC' under Special Requirements) and may have $0 cost-sharing when regulatory conditions are met

Copay waiver or coverage exception for ACA preventive may be requested per ACA rules

Specialty drugs and specialty pharmacy (SP): Specialty drugs may have additional coverage rules and must often be filled through designated specialty pharmacy when applicable (SP flag)

Specialty drugs list and specialty dispensing vendor referenced; see specialty section

Non-covered / exclusions: Non-FDA-approved drugs, repackaged versions, and certain compounded medications may not be covered

Document notes repackaged/compounded/non-FDA-approved products commonly not covered

Exception and Appeal Process

Exceptions and expedited reviews:

Who may request an exception: Members or prescribing providers may request a Drug List exception by calling the number on the ID card

Call number on ID card to request exceptions

Standard exception timeline: Standard exception decision provided to prescriber within three business days after receipt3 business days

BCBSNM will notify prescriber of decision within three business days

Expedited review / urgent: Expedited review available if the request may jeopardize life, health, or function; decision within 24 calendar hours after receipt24 hours

Expedited review criteria and 24-hour decision timeline per document

What providers must do

Prior Authorization

Obtain prior authorization when PA is indicated

Submit prior authorization (PA) before dispensing when a PA is indicated for the listed specialty/limited-distribution products. PA must be approved for coverage to be applied.

ARIKAYCE
KITABIS PAK
NOXAFIL
CRESEMBA
EPCLUSA pellet pack

Prior Authorization

Prior Authorization may be required

Prior authorization may be required for many specialty, biologic, antiviral, antineoplastic and other selected agents. Submit PA prior to dispensing for coverage consideration.

EPCLUSA pellet pack
HARVONI
MAVYRET
SOVALDI
Selected antineoplastics and specialty biologics (see formulary index for product-level PA rules)

Documentation Required

Exception & expedited review

Exception and expedited review requests are available. Follow the phone/process on the member ID card. Standard exception/appeal reviews are processed within 3 business days; expedited (urgent) reviews are processed within 24 hours when clinical criteria for expedited review are met.

Call number on ID card to request exception or expedited review
Standard: decision within 3 business days
Expedited (urgent clinical need): decision within 24 hours

Billing Rule

Specialty pharmacy (Accredo) enrollment/ordering

Specialty pharmacy (Accredo) enrollment and ordering are required for designated specialty products. Providers should route prescriptions electronically, by fax, or by phone to Accredo. Members may be enrolled with Accredo for care coordination and dispensing.

Accredo specialty drugs
Order routing: electronic / fax / phone
Enroll or refer member to Accredo; call the number on the ID card for Accredo contact

Billing Rule

Quantity limits — enforce at claims

Quantity limits (QL) are enforced at claims. Claims exceeding documented quantity limits may be denied or the excess may be billed to the member as their financial responsibility.

Representative examples: 30 tablets / 30 days
Representative examples: 1 ring / 365 days
Representative examples: 300 mLs / 30 days

Step Therapy

Step therapy and Specialty (SP) handling

Step therapy (ST) may apply for certain products. Specialty (SP) products designated on the formulary must be routed through the specialty pharmacy for dispensing and care management.

Examples (select): ENTYVIO PEN, GATTEX, OMVOH, ZYMFENTRA
Step Therapy may require trial of preferred first-line agents before coverage of subsequent medications
Specialty products must be dispensed via the designated specialty pharmacy

Documentation Required

Administrative coverage constraints (AC)

Administrative coverage (AC) codes indicate payer-specific billing, age or access constraints. Check the formulary entry for product-level administrative coverage details.

Examples: ANNOVERA; select contraceptives; certain sodium fluoride products
AC indicates special billing/age/access rules that must be followed

Billing Rule

Use formulary index to locate detailed rules

Use the formulary index to find the detailed policy page for each product. The index shows which products have PA, QL, ST, SP, AC or other special requirements; consult the detailed product-level rules before prescribing or dispensing.

Consult formulary index for product-level PA / QL / ST / SP / AC rules
Refer to detailed policy pages for documentation and submission requirements

Formulary code groups and status

Formulary medication list codes (drug names and strengths as listed)mixedCovered

AMPICILLIN	ampicillin (multiple strengths)
AUGMENTIN	amoxicillin-clavulanate (various strengths)
DICLOXACILLIN SODIUM	dicloxacillin sodium
PENICILLIN V POTASSIUM	penicillin V potassium
CEFPODOXIME PROXETIL	cefpodoxime proxetil
CEFPROZIL	cefprozil
CEFUROXIME AXETIL	cefuroxime axetil
CEPHALEXIN	cephalexin
FIDAXOMICIN / DIFICID	fidaxomicin (Dificid)
ERYTHROMYCIN (EES)	erythromycin (EES)

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Medications with Prior Authorization (PA) noted in this excerptmixed

FIDAXOMICIN / DIFICID	PA often required for fidaxomicin
SIRTURO (BEDAQUILINE)	PA for bedaquiline (TB specialty agent)
FLUCYTOSINE (ANCOBON)	PA for flucytosine
VORICONAZOLE (VFEND)	PA may be required
EPCLUSA (all forms)	PA commonly noted for Epclusa (HCV)
MAVYRET	PA may apply
HARVONI	PA commonly required
GENVOYA / STRIBILD / GENV0YA	PA for certain HIV regimens
PAXLOVID	PA may be required per plan
XOFLUZA	PA may apply

Medications with Quantity Limits (examples)mixed

Oseltamivir 30/45/75 mg; suspension	QL examples for antiviral oseltamivir (caps & susp)
Valacyclovir 500 mg; 1 g	QL examples for antiviral valacyclovir
Nitrofurantoin formulations	QL examples for nitrofurantoin
Metronidazole 250/500 mg	QL examples
SMX-TMP formulations	QL examples (Bactrim)
Linezolid tab 600 mg; susp	QL examples

Drugs with explicit Requirements/Limitsmixed

PEGASYS 180 mcg	may have administration and specialty benefit requirements
PREZISTA suspension 100 mg/mL	oral suspension with pediatric dosing requirements
RELENZA DISKHALER 5 mg/act	inhaled antiviral with age and administration limits
RIBAVIRIN formulations	often combined with interferon or direct-acting antivirals; program requirements
RITONAVIR (NORVIR) packets	special handling and combination rules

Vaccines with Requirements/Limits = ACmixed

ABRYSVO RSV pre-fusion 120 mcg/0.5 mL	ACA preventive designation noted
ActHIB (Haemophilus b) vaccine	AC designation for eligible populations
AFLURIA 2025-2026 influenza vaccines	seasonal influenza presentations (AC per plan)
COMIRNATY 2025-26 COVID-19 mRNA (Pfizer)	AC preventive vaccine presentations
GARDASIL 9 HPV vaccine	AC preventive designation
HEPLISAV-B / ENGERIX-B / VAQTA hepatitis vaccines	AC hepatitis B vaccine presentations
PNEUMOVAX 23 / PREVNAR 20	pneumococcal vaccines (AC)
SHINGRIX zoster vaccine	AC preventive vaccine

Drugs listed without Requirements/LimitsmixedCovered

AMPICILLIN	no special requirements noted in excerpt
AUGMENTIN	standard coverage
PENICILLIN V POTASSIUM	standard coverage
CEFUROXIME AXETIL	standard coverage
CEPHALEXIN	standard coverage
DOXYCYCLINE	standard coverage
MINOCYCLINE	standard coverage
CIPROFLOXACIN	standard coverage
LEVOFLOXACIN	standard coverage
NEOMYCIN	standard coverage

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Exceptions, appeals, specialty pharmacy process

Specialty Pharmacy (Accredo) Enrollment/Ordering

Process to use Accredo for specialty medications:

How providers submit specialty prescriptions to Accredo: Provider sends prescription to Accredo electronically, by fax or by phone

Provider can find prescriber contact info at accredo.com/prescribers per document

Accredo member enrollment and first-fill setup: After receipt, Accredo will contact member to complete enrollment and first fill setup

Accredo provides one-on-one support, free shipping, refill reminders and 24/7 support per document

Member phone contact for Accredo: Members may call Accredo at 833-721-1619 to initiate or transfer prescriptions

Accredo phone number provided in specialty pharmacy section and provider_actions

Members or prescribers may request a Drug List exception by calling the number on the member ID card. BCBSNM will provide a standard exception decision within three business days of receipt and offers an expedited review with a decision within 24 calendar hours when the request may jeopardize life, health, or function. If a request is denied, the plan will explain why and will offer a covered alternative drug when applicable.

Formulary product requirements & limits (per product)

Formulary product requirements/limits (per drug)

Each listed drug entry includes Requirements/Limits indicators such as PA (prior authorization), QL (quantity limit with specified quantity/timeframe), SP (specialty pharmacy), AC (administrative coverage) or blank when none specified. Examples below show product-level indicators and the exact thresholds when listed.

Selected product-level Requirements / Limits (examples): ARIKAYCE: PA; QL 235.2 mLs/28 days; SPPA; QL 235.2 mLs/28 days; SP

Source product entry shows ARIKAYCE with PA, QL and SP

KITABIS PAK (tobramycin): PA; QL 56 containers/56 days; SPPA; QL 56 containers/56 days; SP

Product entry shows KITABIS PAK with PA, QL and SP

TOBRAMYCIN (nebulized) examples: Some formulations QL 56 containers/56 days; SP; PA noted for some formulationsQL 56 containers/56 days

Product entries list tobramycin inhalation products with QL and SP; some formulations have PA

NOXAFIL (posaconazole): PA for multiple formulations (posaconazole susp/DR tabs) — PA noted on posaconazole susp and DR tabsPA

Product entries: NOXAFIL posaconazole with Requirements/Limits = PA

EPCLUSA pellet pack (sofosbuvir-velpatasvir): PA; QL 28 tablets/28 days; SPPA; QL 28 tablets/28 days; SP

EPCLUSA pellet pack entry shows PA, QL and SP

HARVONI / SOVALDI / MAVYRET (HCV agents): Many HCV products labeled PA; QL (common 30 tablets/30 days or packet limits) and SP where listedPA; QL 30 tablets/30 days (examples); SP

HARVONI and SOVALDI entries show PA, QL, SP; MAVYRET entries show PA and QL thresholds

REPATHA (PCSK9 inhibitor): PA; QL 6 syringes/28 days (or 6 pens/28 days for auto-injector)PA; QL 6 syringes/28 days

REPATHA entry shows PA and QL (6 syringes/28 days) and Repatha SureClick with 6 pens/28 days

PEGASYS and other injectables: PEGASYS: PA; SP (peginterferon entries show SP and PA where listed)PA; SP

PEGASYS listed as PA and SP in antiviral section

ENTRESTO / PAH agents / Pulmonary products: Examples: ENTRESTO QL 240 capsules/30 days; OPSUMIT (macitentan) PA, QL 30 tablets/30 days, SP; TYVASO products PA and QL per kit/cartridge limitsQL 240 capsules/30 days; PA QL 30 tablets/30 days; PA QL (cartridges/amplules)

Cardio/PAH product entries include explicit PA and QL thresholds

Quantity Limit examples (selected): Examples from the list: azithromycin QL 60 tablets/180 days; clarithromycin ER QL 28 tablets/30 days; NUZYRA QL 30 tablets/180 days; BAXDELA QL 28 tablets/180 days; itraconazole cap QL 120 capsules/30 days; itraconazole oral soln QL 1200 mLs/30 days; ENTYVIO PEN QL 2 pens/28 days; SUCRAID QL 300 mLs/30 days; ANNOVERA QL 1 ring/365 daysvaries per product as listed; see each product line for exact QL

Multiple threshold examples taken verbatim from product entries and thresholds section

Specialty (SP) designation examples: Many specialty biologics and complex therapies are flagged SP (examples: ACTHAR, PROCYSBI, ENTYVIO PEN, GATTEX, OMVOH, ZYMFENTRA, HETLIOZ) and frequently have PA and QL entriesSP with PA/QL as listed

SP designation indicated on product entries where applicable

Administrative Coverage (AC) examples: Vaccines and some contraceptives and fluoride products show AC (e.g., ABRYSVO, COMIRNATY, ANNOVERA) meaning administrative coverage conditions applyAC

AC marking indicates ACA/preventive or other administrative coverage conditions per vaccine/contraceptive listings

Enforcement note: When a product shows PA in Requirements/Limits, providers must submit prior authorization before coverage is approved; when QL is exceeded claims may be denied or member may be financially responsibleSee PA/QL for each product

Provider actions: obtain prior authorization when PA is indicated; enforce QL values; use Accredo for specialty SP products

Selected high-value quantity limits

ANNOVERAQL 1 ring/365 days

Most oral contraceptives (examples)QL 28 tablets/21 days

Levonorgestrel (emergency)QL 2 tablets/365 days

Arikayce (amikacin liposome inh)QL 235.2 mLs/28 days

Kitabis Pak (tobramycin nebule)QL 56 containers/56 days

PAXLOVID (6x150 & 5x100 pack)QL 11 tablets/30 days

OZEMPIC (some pen strengths)QL 1 pen/28 days

Insulins / many injectablesQL 100 mLs/30 days

Background & definitions

The formulary is selected by a committee of physicians and pharmacists who review FDA‑regulated drugs and consider safety, efficacy, and cost when making coverage and tiering decisions. Drug tier placement determines the member payment amount for a prescription; some products that are provider‑administered may be covered under the medical benefit rather than the pharmacy benefit.

Term	Definition
PA	Prior Authorization — your doctor must submit a request and get approval before medication may be covered; noted as 'PA' in the Special Requirements column.
ST	Step Therapy — you may need to try a first-line, cost‑effective medication before coverage is available for the requested drug; noted as 'ST'.
QL	Quantity Limit — maximum dispensed amount per time period as listed (e.g., '30 tablets/30 days'); shown as 'QL' in Special Requirements.
AC	ACA preventive / Administrative Coverage — products marked 'AC' may have specific administrative coverage rules and may qualify for ACA preventive coverage ($0 cost‑sharing) if regulatory conditions met.
SP	Specialty drug / Specialty Pharmacy — specialty designation indicating additional handling, may require dispensing through designated specialty pharmacy (e.g., Accredo); shown as 'SP'.
P/NP	Formulary tier indicators (P = Preferred, NP = Non‑Preferred, plus variants NP+/P+ etc.) — determine member payment tier placement; tier meanings defined elsewhere in plan materials.

OpenPayer

BCBSNM 2025 Drug List (partial)

Coverage summary & scope

What providers must do

Formulary code groups and status

Exceptions, appeals, specialty pharmacy process

Formulary product requirements & limits (per product)

Background & definitions

Clinical evidence

Revision history