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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBlue Cross Blue Shield NM Drug List Coverage | Ope…
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    CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

    2025 Drug List (Pharmacy Benefit Formulary) — Coverage Criteria

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    This document is Blue Cross and Blue Shield of New Mexico's 2025 pharmacy drug list describing covered outpatient prescription drugs, tier placement, specialty drug handling, and administrative programs (PA, ST, QL) that affect members and prescribing providers.

    Policy Summary
    PayerBlue Cross Blue Shield - New Mexico
    Policy2025 Drug List (Pharmacy Benefit Formulary) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual formulary publication (no material change)
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a drug line is flagged 'PA' before dispensing to avoid claim denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ~120distinct drug line items
    manyentries with Prior Authorization (PA)
    multipleentries with Quantity Limits (QL)
    6member payment tiers described
    Accredospecialty pharmacy partner

    Coverage stance and per-product rules

    Coverage stance for listed drugs

    Drugs are covered with the listed Drug Tier and are subject to Requirements/Limits when indicated.

    General coverage entries: Drugs listed with a Drug Tier value are included on the formulary; entries that include 'PA', 'QL', or 'SP' require prior authorization, are subject to quantity limits, or are managed via specialty pharmacy respectively.

    See individual drug lines for specific QL or PA requirements.

    Per-product coverage rules

    Coverage with conditions as listed per product (PA, QL, SP flags are the gating criteria).

    Per-product rules: Each drug entry includes a Drug Tier and Requirements/Limits field; items marked PA require prior authorization, items marked QL have defined quantity limits, and items marked SP are managed under specialty pharmacy. Examples: SUCRAID requires PA and QL; ENTYVIO PEN requires PA and QL (2 pens/28 days); many bowel-prep products are listed with AC administrative controls.

    Consult the specific formulary line for exact PA, QL, SP designations and numeric limits (e.g., 'QL (2 pens/28 days)', 'QL (60 tablets/30 days)').

    Policy Summary
    PayerBlue Cross Blue Shield - New Mexico
    Policy2025 Drug List (Pharmacy Benefit Formulary) — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeAnnual formulary publication (no material change)
    Effective DateOct 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization when a drug line is flagged 'PA' before dispensing to avoid claim denial.
    SourceLink
    On This Page
    Coverage stance and per-product rulesCode and quantity-limit examplesAuthorization, step therapy, documentation, and denial risksStep therapy rules and presenceQuantity limits and typical supply rulesMedical vs pharmacy benefit and specialty pharmacy routingContext and scope notesKey terms and abbreviations

    Drugs included on this 2025 Drug List are covered according to the Drug Tier shown for each line item and are subject to any Requirements/Limits (for example, PA = prior authorization, QL = quantity limits, SP = specialty program) noted on the product line. Drugs that are not shown on the list are not covered. Providers and prescribers should consult the specific drug line for any utilization controls and follow payer procedures when PA, QL, or SP are indicated.

    Within the segments reviewed here there are no explicit exclusion statements beyond the general guidance that drugs not listed are not covered. The document lists drug entries with their Drug Tier and Requirements/Limits fields; reviewers should rely on the per-product line for coverage details rather than expecting separate exclusion language in this segment.

    The excerpted lines do not present specific exclusion criteria for the products shown. Coverage determinations in these chunks are expressed via tier placement and the Requirements/Limits annotations rather than standalone exclusion clauses.

    This segment lists formulary tiers and utilization controls for individual products but contains no separate exclusion statements; coverage conditions are applied per product through the Requirements/Limits field (e.g., AC, PA, QL, SP).

    No explicit clinical exclusion statements appear in these chunks. Entries are limited to Drug Tier assignment and administrative controls such as PA, QL and SP, which govern coverage and claim adjudication rather than listing clinical exclusions.

    The reviewed excerpts do not include explicit clinical exclusions. Instead, coverage is managed by formulary annotations and utilization management programs (for example, some inhaled aminoglycosides and tobramycin products are noted with PA, QL, and SP), which may limit coverage if program requirements are not met.

    Drugs that have not received FDA approval are not covered under the plan; non–FDA‑approved agents are specifically excluded from coverage per the document's coverage considerations.

    Within the provided excerpt there are no items explicitly designated as 'Not Medically Necessary' (NMN). The document instead indicates coverage limits and administrative controls for listed products; NMN determinations are not specified in these chunks.

    Code and quantity-limit examples

    Formulary drug entries (sample)mixed
    amoxicillin (trihydrate) chew tab 125 mg, 250 mgamoxicillin chewable tablets — listed with Drug Tier = NP
    azithromycin tab 250 mgZithromax z‑pak — QL (60 tablets/180 days)
    ARIKAYCE amikacin sulfate liposome inhal susp 590 mg/8.4mlListed NP with PA and QL (235.2 mls/28 days), SP
    TOBI PODHALER tobramycin inhal cap 28 mgListed NP with QL (224 capsules/56 days), SP
    DIFICID fidaxomicin tab 200 mgDrug Tier = P
    EPCLUSA sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mgDrug Tier = P
    Drug listing (no billing codes in excerpt)mixed
    NDC not listedNDCs are not provided in these chunks; drugs are listed by name and formulation only.
    Specified Quantity LimitsmixedCovered
    QL (3 packs/30 days)aprepitant capsule therapy pack 80 & 125 mg (Emend tripack) quantity limit
    QL (2 capsules/30 days)aprepitant 40 mg quantity limit
    QL (9 kits/30 days)EMEND aprepitant oral suspension 125 mg kits quantity limit
    Specialty biologic codesmixedCovered
    PAPrior Authorization required for OMVOH / OMVOH/OMVOH (mirikizumab) presentations as noted
    QL (2 pens/28 days)Quantity limit for OMVOH auto-injector (2 pens/28 days)
    Ulcer drug limits and PAmixedCovered
    QL (60 capsules/30 days)dexlansoprazole 60 mg quantity limit
    PA, QL (60 packets/30 days)omeprazole-sodium bicarbonate powder pack for suspension — Prior Authorization and quantity limit (60 packets/30 days)
    Quantity Limit examples
    Example QL values60 tablets/180 days; 56 containers/56 days; 224 capsules/56 days; 235.2 mLs/28 days
    Other sample QL120 capsules/30 days; 90 tablets/30 days; 30 tablets/30 days
    Formulary noteQL entries are shown in the Special Requirements column and indicate maximum covered quantity in the specified time period
    Insulin monthly volume
    Typical insulin monthly volume (rapid-acting)100 mLs/30 days
    FIASP pen / penfillQL (100 mLs/30 days)
    NOVOLOG and HUMALOG formulationsQL (100 mLs/30 days)
    FOLLISTIM AQ cartridge limit
    FOLLISTIM AQ cartridge QL (300 unit/0.36 mL) - 300 unit presentationQL (15 cartridges/30 days)
    FOLLISTIM AQ cartridge QL (600 unit/0.72 mL)QL (8 cartridges/30 days)
    FOLLISTIM AQ cartridge QL (900 unit/1.08 mL)QL (5 cartridges/30 days)
    Quantity Limits — inhaler and vial examples
    ADVAIR HFA inhalerQL (1 inhaler/30 days)
    Albuterol inhalerQL (2 inhalers/30 days)
    ARNUITY ELLIPTA blister packsQL (30 blisters/30 days)
    Omeprazole QL example
    Omeprazole-sodium bicarbonate (Zegerid) powder/packQL (60 packets/30 days)
    Omeprazole-sodium bicarbonate capsulesQL (60 capsules/30 days)
    Documentation notePA may apply to certain omeprazole presentations as indicated on the line
    Aprepitant pack QL
    Aprepitant (EMEND) capsule therapy packQL (3 packs/30 days)
    Aprepitant 40 mg capsulesQL (2 capsules/30 days)
    EMEND oral suspension kitsQL (9 kits/30 days)

    Authorization, step therapy, documentation, and denial risks

    Prior Authorization

    Authorization, step therapy, documentation, and denial risks

    Prior authorization (PA), quantity limits (QL), step therapy (ST), and specialty pharmacy routing (SP) requirements are used across the drug list to manage coverage. Entries marked with "PA" in the Requirements/Limits column require prior authorization before coverage. Many specialty and oncology oral agents and injectables (examples include ARIKAYCE, tobramycin nebulizer solutions, numerous antineoplastics and targeted therapies, and biologic self-injectables) require PA and often have accompanying QL and SP designations. When a PA is required, prescribers must submit a prior authorization request and supporting documentation (diagnosis, prior treatments, clinical rationale) as noted below. Absent required PA/QL/SP authorizations or documentation, claims may be denied or limited.

    • PA flags: Drugs noted with "PA" in Requirements/Limits require prior authorization before coverage (e.g., ARIKAYCE; tobramycin nebu soln when PA listed).
    • Specialty/Oncology: Many specialty and oncology oral agents and injectables require PA and are often routed through specialty pharmacy (SP) with defined QLs (examples: abiraterone, alecensa, brigatinib, cabozantinib, lenvatinib, imatinib, ibrutinib, many others).
    • PA with QL: Several drugs require PA plus an explicit quantity limit (e.g., abiraterone QL (120 tablets/30 days); imatinib 100 mg QL (90 tablets/30 days); many oncology/specialty entries list similar QLs).
    • Specialty channel: Products marked "SP" must follow specialty pharmacy distribution and associated PA procedures (examples: ARIKAYCE, many CF modulators, biologic injectables).
    • Documentation: Prior authorization requests must include diagnosis, prior therapies or failures, dosing plan, and any required clinical information. QL and SP designations imply documentation may be required to justify requested quantity or specialty dispensing.
    • Non-compliance risks: Claims submitted without required PA, exceeding QL, or not following SP routing may be denied or paid at the full cost to the member. Providers should confirm benefit-specific requirements as some plans include additional PAs or STs beyond this list.
    • Step therapy: Step therapy (ST) may require trying preferred first-line medications before coverage of non-preferred agents; ST will be noted with "ST" where commonly applied (some CNS and endocrine agents shown). Specific step sequences are not listed in this excerpt — prescribers should consult plan materials or submit a step-therapy exception if clinically necessary.
    • Exception and expedited review: If a PA or step-therapy exception is denied, BCBSNM will notify the member and prescriber and, when applicable, offer a covered alternative. Expedited reviews are available for requests involving imminent harm — decisions communicated within 24 hours.
    • Operational note: "PA" = prior authorization required; "QL" = quantity limit (shows permitted supply per time period); "SP" = specialty pharmacy required; "ST" = step therapy required. Where multiple flags appear (e.g., "PA, QL, SP"), all listed controls apply and must be met for coverage.
    • Provider action summary: Verify the drug’s Requirements/Limits field, submit PA with supporting documentation when "PA" is present, adhere to QL and SP routing, and request step-therapy exceptions when clinically justified to avoid delays or denials.

    Step therapy rules and presence

    Policy summary
    Try a preferred, first-line medication before coverage of a non-preferred drug when step therapy (ST) applies; if the preferred agent is not appropriate the prescriber may request a step therapy exception.
    Observation
    Multiple product lines include 'PA' and 'SP' in the Requirements/Limits field (examples: ARIKAYCE — PA, QL, SP; TOBI PODHALER — QL, SP; many specialty injectables list PA, SP), indicating prior authorization and specialty-program handling which may imply additional program or step requirements handled by the specialty pharmacy partner.
    PALFORZIA levelRequirements / notes
    Levels 0–11 (multiple dose pack presentations)
    Each PALFORZIA level is listed with Requirements/Limits = SP (specialty handling); no explicit step-failure or step-sequence rules are provided in the excerpt.
    FindingSupport
    Products are flagged with administrative controls (PA, QL, SP) across multiple therapeutic classes but the document excerpt does not display explicit step-therapy sequences or algorithm steps.
    Examples: LENVIMA entries show PA/QL/SP; octreotide and other specialty injectables show SP/PA — flags are present but no step sequences are described in these chunks.
    Agent groupAuthorization/limits noted
    GLP‑1 agonists and select high-cost metabolic agents (examples in excerpt: MOUNJARO, OZEMPIC, RYBELSUS listed elsewhere),
    These products commonly include 'PA' and/or 'QL' annotations in the Requirements/Limits field; the excerpt does not provide an explicit step-therapy sequence for these agents.
    DrugST indicated?
    KERENDIA (finerenone) 10 mg/20 mg
    Requirements/Limits include QL (30 tablets/30 days) and ST — entry explicitly marked with ST indicating step therapy may apply.
    IndicatorInterpretation
    'SP' designation next to a drug
    Drugs marked 'SP' are managed via specialty pharmacy/programs and may be subject to specialty-channel requirements and program-specific step edits; the listing uses SP on many specialty injectables and products.
    Product typeControls noted
    Inhaled products and nebulizer solutions (examples: ADVAIR HFA, albuterol inhalers, nebulized albuterol solutions)
    These are commonly subject to quantity limits (QL) per 30‑day period and may be managed with step edits per formulary programs; specific step sequences are not listed in the excerpt.
    DrugQL / ST noted
    MOVANTIK (naloxegol) 12.5 mg, 25 mg
    Requirements/Limits = QL (30 tablets/30 days); no explicit step edits are provided in this segment.
    ScopeRequirement
    CNS and selected mental‑health agents (examples include AUVELITY, FETZIMA, TRINTELLIX, aripiprazole products, clozapine formulations)
    Entries marked 'ST' indicate step therapy must be followed before coverage; prescribers should document trial and failure or intolerance of preferred agents as required by the step program.
    Example productStep therapy note
    Risperidone orally disintegrating tablets (ODT) and GRALISE (gabapentin once‑daily) formulations
    These entries are annotated with 'ST' in the Requirements/Limits field (and QL values), indicating that step therapy (trial of preferred agents) applies before coverage of the listed formulation.
    Agent / flagImplication
    Entries such as octreotide, Omnitrope, and other specialty injectables marked 'SP'
    When 'SP' is present the product is handled through specialty pharmacy processes and may also carry PA and QL controls; where 'ST' appears on specialty/high‑cost agents it indicates step therapy requirements apply.

    Quantity limits and typical supply rules

    Typical day supply
    Typical day supply30-day supply typical; some plans allow up to 90-day maintenance supply
    Dispensing limits purposeLimits encourage medication use consistent with FDA labeling and are shown as QL in the Special Requirements column
    Exception processProviders may submit exceptions when greater quantity or step therapy exemption is clinically appropriate
    azithromycin tablet QL examples
    Azithromycin tab 250 mgQL (60 tablets/180 days)
    Azithromycin tab 500 mgQL (60 tablets/180 days)
    Azithromycin tab 600 mgQL (60 tablets/180 days)
    ARIKAYCE amikacin liposome inhal suspension QL example
    ARIKAYCE (amikacin liposome inhalation)QL (235.2 mLs/28 days)
    PA / SP noteARIKAYCE is listed with PA and SP in Special Requirements
    Formulary placementListed as NP (non-preferred) with specified QL
    TOBI PODHALER tobramycin inhal caps QL example
    TOBI PODHALER tobramycin inhalation capsules 28 mgQL (224 capsules/56 days)
    SP designationTOBI PODHALER is managed via Specialty Pharmacy (SP)
    Associated PASome tobramycin/nebulizer presentations list PA in Special Requirements
    Antiretrovirals (Biktarvy) typical QL 30 (example)
    Biktarvy and other antiretroviralsQL (30 tablets/30 days)
    Typical ARV pack QLMost antiretrovirals listed with QL = 30 tablets/30 days
    Formulary noteQLs for ARVs are shown in the Special Requirements column per product line
    XIFAXAN 550 mg QL
    XIFAXAN (rifaximin) 550 mgQL (60 tablets/30 days)
    Formulary placementListed with QL in Special Requirements column
    Coverage noteRefer to product line for any PA or additional restrictions
    Abiraterone acetate 250 mg QL 120 tablets
    Abiraterone acetate 250 mgQL (120 tablets/30 days)
    Abiraterone acetate 500 mgQL (60 tablets/30 days)
    PA and SPBoth strengths are listed with PA and SP in Special Requirements
    Abiraterone acetate 500 mg QL 60 tablets
    Abiraterone acetate 500 mgQL (60 tablets/30 days)
    PA / SPEntry shows PA and SP as Requirements/Limits
    Formulary noteListed as NP with utilization controls
    Multiple specialty/oncology agents — assorted QL values
    Assorted specialty/oncology QLsVarious QLs shown (examples: 240 capsules/30 days, 120 tablets/30 days, 30 tablets/30 days, 2 syringes/28 days)
    PA and SP commonMany oncology agents are listed with PA and SP alongside QL
    Refer to line itemConsult the specific product line for exact QL, PA, and SP details
    Dasatinib 20 mg (Sprycel) QL 90 tablets
    Dasatinib 20 mg (Sprycel)QL (90 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Formulary classificationEntry shown as NP with utilization controls
    Dasatinib 50-140 mg (Sprycel) QL 30 tablets
    Dasatinib 50–140 mg (Sprycel)QL (30 tablets/30 days)
    PA / SPHigher-strength formulations list PA and SP alongside QL
    Provider noteObtain PA when indicated before dispensing
    ERIVEDGE vismodegib 150 mg QL 30 capsules
    ERIVEDGE (vismodegib) 150 mgQL (30 capsules/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Formulary placementSee product line for PA documentation requirements
    FOTIVDA tivozanib QL 21 capsules
    FOTIVDA (tivozanib) capsQL (21 capsules/28 days)
    PA / SPEntry indicates PA and SP in Requirements/Limits
    Pack-specific QLQL shown per capsule pack size and 28‑day period
    Imatinib 100 mg QL 90 tablets
    Imatinib 100 mg (Gleevec)QL (90 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Higher-strength noteImatinib 400 mg has a different QL (60 tablets/30 days)
    Imatinib 400 mg QL 60 tablets
    Imatinib 400 mg (Gleevec)QL (60 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Formulary guidanceRefer to product line for authorization procedures
    LONSURF trifluridine‑tipiracil QL 80 tablets
    LONSURF (trifluridine‑tipiracil)QL (80 tablets/28 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Pack/therapy noteTherapy packs and QL specified per product line
    LYNPARZA olaparib QL 120 tablets
    LYNPARZA (olaparib)QL (120 tablets/30 days)
    Strengths coveredIncludes 100 mg and 150 mg tablet presentations as listed
    PA / SPListed with PA and SP in Requirements/Limits for some strengths
    REVUFORJ revumenib QL 240 tablets
    REVUFORJ (revumenib) 25 mgQL (240 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Alternate strengthsOther strengths have proportionate QLs (see product lines)
    RUBRACA rucaparib QL 120 tablets
    RUBRACA (rucaparib)QL (120 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    StrengthsMultiple tablet strengths included under same QL provision
    TAGRISSO osimertinib QL 30 tablets
    TAGRISSO (osimertinib)QL (30 tablets/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Dose formsTablet presentations 40 mg and 80 mg share the QL per 30 days
    Combined oral contraceptives QL 28 tablets
    Combined oral contraceptives (standard packs)QL (28 tablets)
    NUVARING vaginal ringQL (1 ring)
    Levonorgestrel emergency 1.5 mgQL (2 tablets/365 days)
    Levonorgestrel emergency QL 2 tablets
    Levonorgestrel emergency (1.5 mg)QL (2 tablets/365 days)
    Coverage noteShown with AC and QL in Special Requirements column
    Patient counselingQL reflects emergency single‑use dosing limits
    NUVARING QL 1 ring
    NUVARING (etonogestrel‑ethinyl estradiol ring)QL (1 ring)
    Supply periodQL corresponds to typical 21‑day ring usage as shown in product line
    Requirements/LimitsListed with AC and QL in Special Requirements column
    Rapid-acting insulins QL 100 mLs
    Rapid‑acting insulins (FIASP, HUMALOG, NOVOLOG, LYUMJEV)QL (100 mLs/30 days)
    Most insulins (pen/cartridge/syringe)Common QL = 100 mLs/30 days across presentations
    DocumentationQuantity limits documented per product line and must be included on PA requests when required
    Antidiabetics QL 30 tablets (example)
    Antidiabetic oral agents (example: FARXIGA, GLYXAMBI)QL (30 tablets/30 days)
    Typical maintenance supply30 tablets/30 days is the common QL for many oral antidiabetics
    PA/QL noteSome GLP‑1 agonists and high‑cost antidiabetics may also list PA and different QLs
    Most listed insulins QL 100 mLs
    Most listed insulinsQL (100 mLs/30 days)
    Includes basal, rapid, and intermediate acting presentationsPen, cartridge, and vial formats shown with same QL
    Provider documentationPrescribers should include indication and quantity on PA when required
    FOLLISTIM AQ cartridges QL 15/8/5
    FOLLISTIM AQ cartridgesQL (15 / 8 / 5 cartridges/30 days) depending on cartridge strength
    Product‑specific QL300 U, 600 U, 900 U cartridge presentations have distinct QLs as listed
    Specialty routingFOLLISTIM AQ entries include SP designation
    PALYNZIQ QL example
    PALYNZIQ (pegvaliase)Listed with PA and SP; QL not specified in excerpt
    Specialty handlingPA and SP designations indicate specialty pharmacy routing and authorization
    Provider actionObtain PA where indicated before dispensing
    OVIDREL prefilled syringe QL 2 syringes
    OVIDREL prefilled syringe 250 mcgQL (2 syringes/30 days)
    Specialty designationProduct listed with SP indicating specialty pharmacy handling
    Formulary noteQL shown in Special Requirements column per product line
    SOMAVERT QL 30 vials
    SOMAVERT (pegvisomant)QL (30 vials/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    High‑cost biologic noteSpecialty program requirements apply; obtain PA as required
    RAYALDEE QL 60 capsules
    RAYALDEE (calcifediol) cap ER 30 mcgQL (60 capsules/30 days)
    Formulary noteListed as NP with a 60‑capsule monthly QL
    PA/SPCheck product line for any PA or SP flags
    ORILISSA 150 mg QL 30 tablets
    ORILISSA 150 mg (elagolix)QL (30 tablets/30 days)
    ORILISSA 200 mgQL (60 tablets/30 days)
    PA / SPBoth strengths listed with PA and QL in Requirements/Limits
    ORILISSA 200 mg QL 60 tablets
    ORILISSA 200 mgQL (60 tablets/30 days)
    Higher QL for 200 mg strengthAs shown in Special Requirements column
    PA requirementPA listed for elagolix presentations in product line
    VOXZOGO QL 30 vials
    VOXZOGO (vosoritide)QL (30 vials/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Duplicate entry noteVOXZOGO appears more than once in the product list with same QL
    TRYNGOLZA QL 1 injection device
    TRYNGOLZA (olezarsen) injection deviceQL (1 injection device/28 days)
    PA / SPProduct requires PA and specialty handling as listed
    Provider actionObtain PA and route via specialty pharmacy when required
    TYMLOS QL 1.56 mL (pen)/30 days
    TYMLOS (abaloparatide) pen 1.56 mLQL (1.56 mL pen/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Supply periodQL corresponds to monthly pen supply
    YORVIPATH QL 2 pens
    YORVIPATH (palopegteriparatide)QL (2 pens/28 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Provider noteSpecialty routing and PA typically required
    SKYTROFA cartridges QL example
    SKYTROFA cartridgesListed with PA and SP; specific cartridge QL not shown in excerpt
    Specialty handlingEntry includes PA and SP designations indicating specialty pharmacy routing
    Refer to product lineConsult full product line for exact cartridge QL values
    OPFOLDA QL 8 capsules
    OPFOLDA (miglustat)QL (8 capsules/28 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Indication noteUsed for specific genetic indications; specialty handling applies
    Epaned oral solution QL 1200 mL
    Epaned (enalapril oral solution)QL (1200 mLs/30 days)
    PA flagSome oral solutions list PA in Requirements/Limits; check line item
    Large‑volume QLHigh mL QLs are shown for oral liquid formulations
    VOXZOGO duplicate entry QL 30 vials
    VOXZOGO (duplicate)QL (30 vials/30 days) — entry repeated in source
    Consistency noteDocument shows same QL value in multiple locations for VOXZOGO
    PA / SPPA and SP indicated for VOXZOGO
    ADVAIR HFA inhaler QL example
    ADVAIR HFA (fluticasone–salmeterol)QL (1 inhaler/30 days)
    Albuterol inhalerQL (2 inhalers/30 days)
    Advair Diskus blister QLQL (60 blisters/30 days) as shown for diskus formulations
    Albuterol inhaler QL 2 inhalers/30 days
    Albuterol inhaler (aerosol)QL (2 inhalers/30 days)
    Nebulizer solution volumesExamples include QL (60 mLs/30 days) and QL (120 vials/30 days) depending on presentation
    Dispensing limitsLimits aim to align with intended FDA dosing intervals
    ARNUITY ELLIPTA QL 30 blisters/30 days
    ARNUITY ELLIPTAQL (30 blisters/30 days)
    Multiple inhaler examplesSome inhaled products have QL 1–3 inhalers/30 days or specified blister/vial limits
    Provider guidanceRefer to product line for presentation‑specific QL and PA requirements
    NUCALA QL 3 mL/28 days or 1 syringe/28 days
    NUCALA (mepolizumab)QL (3 mL/28 days or 1 syringe/28 days depending on presentation)
    PA and SPNUCALA entries include PA and SP in Requirements/Limits
    Presentation‑specific QLDifferent presentations (auto‑injector vs prefilled syringe) have distinct QLs
    TRIKAFTA QL 56 packets/28 days
    TRIKAFTA (CF modulator)QL (56 packets/28 days)
    PA / SPListed with PA and SP in Requirements/Limits
    CF therapy notePacket QL corresponds to regimen dosing; check product line for details
    Multiple inhalers QL examples
    Multiple inhalers examples1–3 inhalers/30 days or specified blister/vial limits per drug
    Examples includedASMANEX, BREO, DULERA and others show varied QLs depending on formulation
    Provider actionCheck the Special Requirements column for exact QL per presentation
    Pirfenidone QL varies by formulation
    Pirfenidone formulationsQL varies by formulation: 21 tablets/180 days or 180 capsules/30 days depending on formulation
    PA / SPPirfenidone entries include PA and SP in Requirements/Limits
    Formulary detailDifferent tablet vs capsule presentations have distinct QLs
    Diphenoxylate with atropine liquid QL 1200 mL/30 days
    Diphenoxylate with atropine liquid (Lomotil)QL (1200 mLs/30 days)
    PA noteSome liquid presentations carry PA flags; check product line
    Large‑volume QLHigh mL QLs applied to certain liquid antidiarrheals
    Dexlansoprazole 60 mg QL 30 capsules
    Dexlansoprazole 60 mg (Dexilant)QL (30 capsules/30 days)
    Omeprazole powder pack noteSimilar ulcer agents may show QL (60 packets/30 days) and PA as indicated
    Formulary placementListed with QL in Special Requirements column
    Aprepitant packs and capsules QL examples
    Aprepitant therapy pack (Emend tripack)QL (3 packs/30 days)
    Aprepitant 40 mg capsulesQL (2 capsules/30 days)
    EMEND oral suspension kitsQL (9 kits/30 days)
    ENTYVIO PEN QL 2 pens/28 days
    ENTYVIO PEN (vedolizumab auto‑injector)QL (2 pens/28 days)
    PA / QLENTYVIO PEN requires PA and has a 2‑pen/28‑day QL
    Specialty handlingListed with SP indicating specialty pharmacy routing
    MOVANTIK QL 30 tablets/30 days
    MOVANTIK (naloxegol)QL (30 tablets/30 days)
    Formulary noteListed with QL in Special Requirements column
    Provider guidanceAdhere to QL when submitting claims; PA may be required for other agents in class
    Multiple CNS oral formulations — assorted QL values
    CNS oral formulations (assorted)Varies by product — common QLs include 30/30 days, 60/30 days, 90/30 days, 180/periods as listed per product
    ExamplesAripiprazole QL 30/30 days; Clozapine ODT QLs 90–270 tablets/30 days; Belsomra QL 30/30 days
    ST/QL interplaySome CNS agents carry ST (step therapy) in addition to QL; follow Special Requirements column
    Risperidone oral solution QL 480 mL
    Risperidone oral solution 1 mg/mL (Risperdal)QL (480 mLs/30 days)
    Liquid formulation QLLarge‑volume oral solutions list mL QLs consistent with chronic dosing
    Provider noteDocument indication and quantity on PA when required
    SECUADO patch QL 30 patches
    SECUADO (asenapine transdermal patch)QL (30 patches/30 days)
    STSECUADO listed with ST in Requirements/Limits; step therapy may apply
    Specialty notePatch QL reflects monthly patch supply
    IMCIVREE QL 10 vials
    IMCIVREE (setmelanotide)QL (10 vials/30 days)
    PA / SPIMCIVREE requires PA and is managed under SP
    Specialty biologic noteVial‑based QL specified for injectable specialty agents
    WEGOVY QL 4 pens
    WEGOVY (semaglutide) standard packQL (4 pens/28 days)
    WEGOVY alternate packQL (8 pens/180 days)
    PA / SPListed with PA and QL in Requirements/Limits
    WEGOVY alternate pack QL 8 pens
    WEGOVY alternate packQL (8 pens/180 days)
    Coverage noteAlternate pack QL applies per product line; PA listed
    Supply period180‑day QL shown for alternate larger pack
    ZEPBOUND QL 4 pens
    ZEPBOUND (tirzepatide)QL (4 pens/28 days)
    PA / SPListed with PA and QL in Requirements/Limits
    Weight‑management class noteSame QL convention used for other GLP‑analog weight‑management injectables
    LUMRYZ QL 30 packets
    LUMRYZ (sodium oxybate) packQL (30 packets/30 days)
    Starter packLUMRYZ STARTER PACK QL (28 packets/180 days)
    PA / SPBoth entries list PA and SP in Requirements/Limits
    LUMRYZ STARTER PACK QL 28 packets
    LUMRYZ STARTER PACKQL (28 packets/180 days)
    Starter kit QLStarter packs may have shorter‑interval QLs noted separately
    PA requiredPA is indicated for LUMRYZ entries
    PLEGRIDY auto-injector QL 2 pens
    PLEGRIDY auto‑injectorQL (2 pens/28 days)
    PA / SPPLEGRIDY entries include PA and SP in Requirements/Limits
    Starter/kit variantsStarter packs have separate QL/PA entries as noted
    SODIUM OXYBATE QL 540 mLs
    SODIUM OXYBATE oral solutionQL (540 mLs/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    High‑volume liquid QLConsistent with other oxybate formulations (XYWAV) at same QL
    XYWAV QL 540 mLs
    XYWAV oral solutionQL (540 mLs/30 days)
    PA / SPListed with PA and SP in Requirements/Limits
    Patient safety noteHigh‑volume controlled substance — dispensing limits apply
    BELBUCA QL 60 films
    BELBUCA buccal filmQL (60 films/30 days)
    Formulary placementQL shown in Special Requirements column for buccal opioid formulations
    Provider guidanceAdhere to QL; some opioid formulations have additional state limits
    Fentanyl transdermal patch QL 15 patches
    Fentanyl transdermal patchQL (15 patches/30 days)
    Formulary controlApplied to fentanyl patch presentations as shown
    Controlled substance noteState dispensing laws may further restrict quantities
    NUCYNTA ER QL 60 tablets
    NUCYNTA ER (tapentadol ER)QL (60 tablets/30 days)
    Opioid QL conventionsExtended‑release opioid products often have monthly QLs to limit supply
    PA/QL documentationProviders should document clinical rationale when exceeding QL
    Tramadol IR 50 mg QL 240 tablets
    Tramadol IR 50 mgQL (240 tablets/30 days)
    High QL for short‑acting analgesicSome immediate‑release formulations show larger QLs (e.g., tramadol 240/30 days)
    Prescribing cautionAdhere to state and plan‑level dispensing limits for controlled substances
    XTAMPZA ER QL 240 capsules
    XTAMPZA ER (oxycodone ER)QL (240 capsules/30 days)
    ER opioid QLExtended‑release opioid QLs set to monthly maximums per formulary
    Utilization controlsPA/QL and state regulations may apply
    Adalimumab products QL typically 2 pens/2 syringes
    Adalimumab products (various biosimilars/brands)Typical QL = 2 pens or 2 syringes per 28 days
    PA / SPMost adalimumab entries list PA and SP in Requirements/Limits
    Formulary routingSpecialty pharmacy distribution commonly required for self‑injectable biologics

    Medical vs pharmacy benefit and specialty pharmacy routing

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    Context and scope notes

    Specialty drugs are therapies for complex conditions that often require special handling, clinical support, or distribution through specialty pharmacy channels. They may be oral, topical, or injectable and can be self‑administered or administered by a health care professional; medications given by a provider may be covered under the medical benefit rather than the pharmacy benefit. The drug list is updated regularly based on safety, efficacy, cost, and clinical committee review.

    Key terms and abbreviations

    Specialty drugs definition
    Specialty drugs — definitionMedications for complex conditions that may require special handling/support; can be oral, topical, or injectable and may be provider‑administered
    Site‑of‑care implicationMedications administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit
    Where to checkFor current specialty medication list visit MyPrime.com or bcbsnm.com
    Member payment tiers
    Member payment tiersPreferred Generic (Tier 1); Non‑Preferred Generic (Tier 2); Preferred Brand (Tier 3); Non‑Preferred Brand (Tier 4); Preferred Specialty (Tier 5); Non‑Preferred Specialty (Tier 6)
    Tier notationPreferred/Non‑Preferred indicated by p / np / P / NP next to drug name
    Group‑specific coverageA '+' indicates group‑specific coverage; refer to member plan materials
    Quantity Limit (QL) definition
    Quantity Limit (QL) — definitionMaximum quantity allowed over a specified period as shown in the Special Requirements column (e.g., 60 tablets/30 days)
    Purpose of QLEncourages medication use consistent with FDA labeling and limits excess dispensing
    Where shownQL is displayed per product line; exceptions require documentation or PA
    Prior Authorization (PA) definition
    Prior Authorization (PA) — definitionCoverage requires authorization before filling for certain drugs; marked 'PA' in Special Requirements column
    DocumentationPA requests should include diagnosis, prior treatments, and clinical rationale as required by the payer
    Denial riskClaims may be denied if PA is required but not obtained
    Special Program (SP) definition
    Special Program (SP) — definitionDenotes specialty pharmacy or program handling requirements; SP indicates routing through specialty channels
    ImplicationSP products may require specialty pharmacy dispensing and additional documentation
    ExamplesMany biologics, CF modulators, and high‑cost injectables are marked SP
    Authorization and limits codes
    Authorization and limits codesPA = Prior Authorization; QL = Quantity Limit (format e.g., 60 tablets/30 days); SP = Specialty pharmacy handling; AC = Administrative control
    Where usedCodes appear in the Special Requirements column beside each product line
    Action requiredFollow PA/SP procedures and document QL when submitting claims