2026 Pharmacy Drug List and Coverage Guide — Drug List and Coverage Criteria
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Blue Cross and Blue Shield of New Mexico's 2026 drug list and companion guidance describing covered outpatient pharmacy drugs, tiering, specialty drug handling, prior authorization, step therapy, quantity limits, and member/provider processes.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Rules
General coverage conditions
Covered when ALL of the following are met
Drugs not shown are not covered
For medications listed, PA is generally noted next to the medication in the Special Requirements column; some plans may require PA on additional medications
Step therapy (ST) is noted next to medications when applicable; prescribers may request step therapy exceptions
Dispensing limits (QL/DL) and supply (30- or 90-day) conventions are described in the plan materials
Formulary coverage stance
Coverage entries shown with tiering and utilization management annotations
Examples in the list include antiretrovirals and antifungals annotated with PA/QL/SP where applicable
Formulary coverage and management per drug entry
Coverage indicated per drug entry with formulary tier and management codes
Clinical medical necessity rules are not present in these listing fragments; see full PA criteria where applicable
General coverage conditions
Coverage subject to product-level administrative controls
This segment lists antineoplastics and specialty agents with PA/QL/SP annotations; clinical approval criteria are located elsewhere
Operational coverage conditions
Coverage is contingent on meeting the operational requirements listed per drug presentation
Operational controls are provided inline with product entries (examples: EOHILIA PA+QL; prednisolone solutions QL/PA entries)
Formulary coverage and management by product
Coverage and utilization management decisions for individual drugs as listed below:
See each product line for the exact Requirements/Limits values
Androgens/Testosterone products
Testosterone formulations have variable requirements:
Providers should submit PA where indicated and follow per-product QL
Estrogens and related combination products
Various estrogen therapies are included with tiering and quantity limits:
Contraceptives
Multiple contraceptive products with AC/QL/PA designations:
AC indicates ACA preventive coverage where applicable and coverage may vary by benefit plan
Per-product coverage statements
Coverage and utilization controls as listed per product
This block reflects the per-line controls shown across the formulary; clinical indication criteria are not included in these chunks.
Formulary requirement indicators
Coverage and requirement indicators present in this fragment:
See individual product lines for exact PA requirements
Per-product limits are listed next to each drug name
Examples include ACTHAR, GALAFOLD, IMCIVREE
Consult full policy for step therapy algorithms
Administrative coverage criteria (partial list)
Coverage and administrative requirements for listed products
Examples include SOMAVERT, VOXZOGO, SKYTROFA listed with PA and SP
Cardiovascular drug listings
Standard cardiovascular agents listed
No specific clinical PA criteria are provided in this segment; see per-product entries for PA/QL values
Formulary coverage entries
Coverage is indicated per listed product with associated utilization controls where specified.
No patient-level clinical criteria are present in this fragment; see full policy for medical necessity criteria
Formulary coverage conditions
Coverage is provided according to formulary tier, with additional utilization controls as specified below
This excerpt does not include detailed clinical eligibility criteria; see product-specific policies for clinical PA rules
Drugs are covered only if they appear on the BCBSNM Drug List and are included in the member’s benefit plan. Drugs not shown on the drug list are not covered; repackaged products and medications that have not received FDA approval are also not covered. Some products that have over‑the‑counter equivalents or are used for cosmetic indications may be excluded by the member’s benefit. Refer to the member’s specific plan documents or call the number on the member ID card for coverage determinations.
This document does not present a separate list of explicitly excluded products in the section shown. Instead, individual drug lines identify a Drug Tier and any applicable utilization controls such as PA (prior authorization), QL (quantity limit), SP (specialty pharmacy), or AC. Coverage decisions follow the per‑product annotations shown on the formulary lines.
Coverage is determined by the drug list and the member’s benefit plan. Where a product line shows utilization controls (for example, PA, QL, or SP), the provider must follow those administrative requirements for coverage to be approved. For site‑of‑care questions (for example, drugs administered by a health care professional), refer to plan materials because some products may be covered under the medical benefit rather than the pharmacy benefit.
Formulary Listings and Code Tables
| amoxicillin (trihydrate) chew tab 125 mg, 250 mg | Listed formulary product and strengths |
| amoxicillin (trihydrate) cap 250 mg, 500 mg | Listed formulary product and strengths |
| amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml | Listed formulary product and strengths |
| amoxicillin (trihydrate) tab 500 mg, 875 mg | Listed formulary product and strengths |
| amoxicillin & k clavulanate for susp 200-28.5 mg/5ml; 250-62.5 mg/5ml; 400-57 mg/5ml; 600-42.9 mg/5ml | Listed formulations including Augmentin ES-600 |
| amoxicillin & k clavulanate tab 250-125 mg; 500-125 mg; 875-125 mg; ER 1000-62.5 mg | Tablet strengths listed |
| ampicillin cap 500 mg | Listed product |
| cefadroxil tab 1 gm; cap 500 mg | Cephalosporin entries |
| cefdinir cap 300 mg; for susp 125 mg/5ml, 250 mg/5ml | Cephalosporin entries |
| cefixime cap 400 mg; for susp 100 mg/5ml, 200 mg/5ml | Cephalosporin entries |
Provider Requirements, Prior Authorization & Step Therapy
Submit Prior Authorization when 'PA' is shown
If a medication in the drug list shows 'PA' in the Requirements/Limits or Special Requirements column, the prescriber must submit a prior authorization request and obtain approval before the medication will be covered.
- PA is noted next to products throughout the drug list; absence of an approved PA may result in denial or member responsibility for cost.
PA required for select specialty/antimycobacterial/antifungal agents
Certain specialty antimycobacterial and antifungal agents (examples: ARIKAYCE, KITABIS PAK, tobramycin nebulized solutions, CRESEMBA, posaconazole, itraconazole) are listed with 'PA' (and often QL/SP); prescribers must request prior authorization for these products.
- Tobramycin nebulized solution: Requirements/Limits = PA, QL (280 mls/56 days) and SP (or Bethkis QL 224 mls/56 days) [[chunk 31]]
- CRESEMBA (isavuconazonium): Requirements/Limits = PA [[chunk 33]]
- Itraconazole oral solution/capsules: QL/PA as listed (e.g., QL 1200 mls/30 days; QL 120 capsules/30 days) [[chunk 34]]
EPCLUSA: PA and QL (28 tablets/28 days)
EPCLUSA (sofosbuvir-velpatasvir) requires prior authorization and is quantity-limited to 28 tablets (or 28 packs) per 28 days; it is designated for specialty pharmacy routing.
- EPCLUSA lines show: Requirements/Limits = PA, QL (28 tablets/28 days) and SP [[chunk 39]].
HARVONI: PA and QL (28 tablets/28 days)
HARVONI (ledipasvir-sofosbuvir) requires prior authorization, has a quantity limit of 28 tablets/28 days (or 28 packs/28 days), and is designated specialty pharmacy.
- HARVONI lines show: Requirements/Limits = PA, QL (28 tablets/28 days) and SP [[chunk 40]].
DAA hepatitis C agents: PA, QL, SP
Other direct-acting antivirals for hepatitis C (MAVYRET, VOSEVI, SOVALDI) are listed with prior authorization, specific quantity limits, and specialty pharmacy designation; submit PA and include supporting documentation.
- MAVYRET, VOSEVI, and SOVALDI entries include Requirements/Limits = PA, QL and SP (per product lines in the formulary) [[chunk 47],[chunk 50]].
Obtain PA for listed oncology and specialty drugs
Many antineoplastic and other listed oncology/specialty drugs are marked 'PA' (often with QL and SP); prescribers must obtain prior authorization before dispensing these agents.
- Examples include abiraterone acetate (PA, QL 120 or 60 tablets/30 days) and ALECENSA (PA, QL 240 capsules/30 days) [[chunk 72],[chunk 73]].
- PA is shown adjacent to numerous oncology product lines; lack of PA may trigger denial.
PA indicated in Requirements/Limits field — submit request
Prior authorization is broadly required for many oncology agents and appears in the product Requirements/Limits field; submit PA requests for any product line showing 'PA'.
- Product lines with 'Requirements/Limits = PA' require a PA submission prior to coverage.
PA and QL enforcement for specialty/oncology agents
Many specialty and oncology products include both prior authorization and quantity limits; prescribers must obtain PA and request quantities within the QL shown on the formulary lines.
- Examples: LYNPARZA (PA, QL 120 tablets/30 days), LYTGOBI (PA, QL 84/112/140 tablets/28 days) [[chunk 90],[chunk 99]].
Submit PA for listed non-oncology specialty products (e.g., EOHILIA)
Selected non-oncology products also require prior authorization (examples include budesonide oral suspension EOHILIA and certain hormonal therapies); check product Requirements/Limits and submit PA when 'PA' is shown.
- EOHILIA (budesonide oral suspension) is listed with Requirements/Limits = PA, QL (1800 mls/90 days) [[chunk 108]].
- Some hormonal and specialty products (MYFEMBREE, ORIAHNN) show PA and QL on their lines.
PA required for listed endocrine/specialty agents (e.g., MOUNJARO, OZEMPIC)
Several commonly used endocrinology and specialty products (e.g., certain metformin ER formulations, MOUNJARO, OZEMPIC, TRULICITY) are listed with 'PA' in Requirements/Limits; prescribers must submit PA requests for these products.
- Metformin oral solution Riomet: Requirements/Limits = PA, QL (780 mls/30 days) [[chunk 133]].
- MOUNJARO and OZEMPIC entries include PA and specified QL values [[chunk 134]].
PA required for endocrine and specialty agents (ACTHAR, GENOTROPIN, CRENESSITY)
Multiple endocrine and specialty drugs (examples: ACTHAR, GENOTROPIN, CRENESSITY) are designated 'PA' (and many also 'SP'); the prescriber must obtain prior authorization and route dispensing through specialty pharmacy when required.
- ACTHAR: Requirements/Limits = PA, SP; GENOTROPIN: Requirements/Limits = PA, SP; CRENESSITY: Requirements/Limits = PA, QL (60 capsules/30 days) [[chunk 151],[chunk 155]].
PA and Specialty Pharmacy required for select orphan/specialty agents
Certain specialty/orphan agents (e.g., Kuvan, SKYTROFA, SOMAVERT, STRENSIQ, VOXZOGO) require prior authorization and often specialty pharmacy dispensing; submit PA and use specialty pharmacy routing as indicated.
- Kuvan: PA, SP; SKYTROFA: PA, SP; SOMAVERT: PA, QL (30 vials/30 days), SP; VOXZOGO: PA, QL (30 vials/30 days), SP [[chunk 162],[chunk 163]].
Follow Step Therapy requirements or request exception
If step therapy (ST) is indicated (marked 'ST' on the drug list), the prescriber must document trial of the required first-line agent or submit a step therapy exception if the patient cannot use first-line therapy.
- Step therapy exceptions must be requested by the prescriber or authorized representative by calling the number on the member ID card; decisions communicated within 3 business days (standard) or 24 hours for expedited requests [[chunk 15],[chunk 10]].
Step therapy not fully specified in list — check 'ST' flags
No comprehensive step therapy algorithms are provided in this excerpt; many products are managed by PA, QL, and SP flags rather than explicit ST sequences—check the formulary line for 'ST' where present.
- Where 'ST' appears (e.g., KERENDIA), the prescriber must follow the step requirement or request an exception [[chunk 156],[chunk 36]].
REPATHA: PA and QL (6 syringes/28 days or 6 pens/28 days)
REPATHA (evolocumab) products require prior authorization and have quantity limits of 6 syringes/28 days or 6 pens/28 days; obtain PA prior to dispensing and ensure QL compliance.
- REPATHA prefilled syringe or auto-injector 140 mg: Requirements/Limits = PA, QL (6 syringes/28 days or 6 pens/28 days) [[chunk 198],[chunk 197]].
Obtain PA for listed specialty/high-cost cardiovascular & pulmonary drugs
Many specialty/high-cost cardiovascular and pulmonary agents are listed with 'PA' (and often QL and SP); prescribers must obtain prior authorization before dispensing these products.
- Examples: ENTRESTO (PA, QL 240 capsules/30 days), UPTRAVI (PA, QL 60 tablets/30 days), TYVASO starter kits (PA, QL) [[chunk 200],[chunk 204]].
PA required for specialty/biologic and CF agents (route via SP)
Many specialty/biologic respiratory and cystic fibrosis therapies (examples: FASENRA PEN, NUCALA, TEZSPIRE, KALYDECO, TRIKAFTA) require prior authorization and are subject to quantity limits and specialty pharmacy routing; submit PA and route through specialty pharmacy.
- FASENRA PEN: Requirements/Limits = PA, QL (1 pen/28 days), SP; NUCALA: Requirements/Limits = PA, QL (varies by presentation), SP; TRIKAFTA: Requirements/Limits = PA, QL (varies), SP [[chunk 217],[chunk 224]].
Prior authorization required for products labeled 'PA'
Products explicitly labeled 'Requirements/Limits = PA' (examples shown: BYLVAY, GATTEX, LIVDELZI, LIVMARLI, CIMZIA, ENTYVIO PEN) require prior authorization prior to coverage approval; prescribers must submit PA requests.
- CIMZIA entries show Requirements/Limits = PA and QL (2 kits/28 days or 4 syringes/28 days) [[chunk 239]].
PA required for selected products — submit before dispensing
Selected products across the list require prior authorization before coverage will be approved; prescribers must submit PA requests for any product line indicating 'PA' in Requirements/Limits.
- Examples: PROCYSBI, NUPLAZID and other product lines flagged 'PA' will require PA prior to coverage [[chunk 268]].
Adhere to product-specific quantity limits when dispensing
For products with specified QL (e.g., EPCLUSA 28 tablets/28 days, HARVONI 28 tablets/28 days, REPATHA 6 syringes/28 days), ensure the dispensed quantity adheres to the QL to avoid denial or member cost responsibility.
- EPCLUSA: QL 28 tablets/28 days; HARVONI: QL 28 tablets/28 days; REPATHA: QL 6 syringes/28 days or 6 pens/28 days [[chunk 39],[chunk 40],[chunk 197]].
Avoid exceeding formulary quantity limits (QL)
Prescriptions that exceed plan dispensing or quantity limits (QL) may be denied or result in the member being responsible for the full cost of the medication; ensure prescribed quantities do not exceed the listed QL.
- For certain controlled substances, state law may prohibit coverage of quantities beyond dispensing limits; member could be responsible for full cost [[chunk 10],[chunk 109]].
- Claims exceeding QL may be denied per plan rules [[chunk 20]].
Initial Therapy and Authorization Rules
Initial therapy controls
Initial coverage controls shown per product
No specific clinical initiation criteria are provided in these chunks
Initial administrative requirements
Initial authorization requirements (as provided in this excerpt)
Clinical medical necessity criteria for initiation are not included in this fragment
Initial therapy rules (not specified)
No explicit initial therapy criteria are provided in this excerpt.
Specific clinical initiation rules not included here
Step Therapy Rules and Affected Agents
| Step therapy principle |
|---|
| Try preferred first-line, cost-effective medication unless an exception is granted (prescriber may request a step therapy exception). |
| Note |
|---|
| No explicit step therapy steps are provided in the formulary listing; utilization management is applied per product using prior authorization (PA), quantity limits (QL), and specialty pharmacy (SP) designations as shown on the drug list. |
| ART product management |
|---|
| Several combination antiretroviral (ART) products are subject to quantity limits (commonly QL (30 tablets/30 days) for listed agents such as BIKTARVY, CIMDUO, DELSTRIGO and others); explicit step edits are not specified in these entries. |
| Oncology/specialty step therapy note |
|---|
| Multiple oncology and specialty agents are listed with specialty (SP) and prior authorization (PA) requirements and quantity limits (QL); some products are indicated as subject to step therapy (ST) — specific step sequences are not provided in these chunks. |
| KERENDIA (finerenone) |
|---|
| KERENDIA (finerenone) 10 mg, 20 mg is listed with a quantity limit of QL (30 tablets/30 days) and is marked 'ST' indicating step therapy requirements apply; specific step criteria are not included in these excerpts. |
| AUVELITY |
|---|
| AUVELITY (dextromethorphan HBr–bupropion HCl) is listed with 'ST' in Requirements/Limits, indicating it is subject to step therapy requirements as noted on the drug list. |
| DESVENLAFAXINE ER |
|---|
| DESVENLAFAXINE ER is identified with 'ST' in the Requirements/Limits field in the formulary excerpts, indicating it is subject to step therapy requirements. |
| ESCITALOPRAM OXALATE |
|---|
| ESCITALOPRAM OXALATE (e.g., 15 mg cap) is listed with 'ST' in the Requirements/Limits field, indicating step therapy applies per the drug list notation. |
| FETZIMA |
|---|
| FETZIMA (levomilnacipran) extended‑release capsules are marked 'ST' in the Requirements/Limits column, indicating they are subject to step therapy requirements per the formulary listing. |
| QUETIAPINE FUMARATE (some strengths) |
|---|
| Certain quetiapine fumarate tablet presentations (examples in the listing) include 'QL' and are specifically noted with 'ST' for some strengths — indicating selected strengths are subject to step therapy as shown in the drug list. |
| RISPERIDONE ODT (certain strengths) |
|---|
| Risperidone orally disintegrating tablets (ODT) at certain strengths are listed with QL and are marked 'ST' for selected presentations, indicating step therapy requirements apply to those strengths as shown in the formulary excerpt. |
Quantity Limits and Examples
Site of Care and Specialty Pharmacy
Terminology and Abbreviations
Background and Scope
Specialty drugs are high‑complexity or high‑cost medications used to treat conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis. They may require special handling, patient support, or administration by a health care professional. When a specialty product is administered in a clinical setting it may be billed through the medical benefit; when dispensed for self‑administration it is typically managed through the pharmacy benefit and, when designated, must be routed through a specialty pharmacy partner.
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