2026 Drug List — Pharmacy & Specialty Drugs (Formulary, Utilization Controls, and Prior Authorization Guidance)
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The document is Blue Cross Blue Shield of New Mexico's 2026 Drug List describing covered pharmacy and specialty medications, tiering, coverage rules, and member/provider processes for prior authorization, step therapy, dispensing limits, and exceptions. It affects BCBSNM members and their prescribing providers.
No material clinical or coverage changes in this revision.
Formulary coverage & per-product rules
Formulary coverage & per-product rules
General pharmacy coverage — Covered pharmacy drugs are those listed on the drug list and subject to plan-specific tiers and special requirements. Drugs not listed are not covered. Repackaged and non–FDA-approved drugs are not covered. Refer to member-specific benefit materials for plan limits and exclusions.
ALL of the following
- Drug coverage is limited to drugs shown on the BCBSNM Drug List; drugs not shown are not covered.
- Coverage is subject to plan-specific drug tiers (e.g., P, p, NP, NP) and any Special Requirements/Limits noted on the formulary entry.
- Some products may be excluded if an over-the-counter equivalent exists; compounded, repackaged, and non–FDA-approved drugs are not covered.
- Prior Authorization (PA) may be required when indicated by 'PA' in the Special Requirements column; approval is required before coverage is applied.
- Step Therapy (ST) may be required when indicated by 'ST' in the Special Requirements column; providers may submit step therapy exception requests when medically appropriate.
- Dispensing Limits / Quantity Limits (QL) may apply as noted (e.g., quantity per prescription or per time period); dispensing beyond the QL may result in member financial responsibility.
- Some controlled substances may be subject to state limits that, if exceeded, result in no benefits for the excess quantity.
Billing / code references and quantity-limit examples
Prior authorization, step therapy, documentation & denial risks
Obtain prior authorization when 'PA' is listed
Some medications listed have a Prior Authorization (PA) requirement; when PA is commonly required the drug line shows 'PA' in the Requirements/Limits/Special Requirements column and an approved prior authorization must be obtained before the plan will cover the drug.
- Providers must submit and receive approval of a PA before dispensing PA‑listed drugs to ensure coverage.
PA required for listed inhaled antimicrobials and antifungals
Certain specific products in the formulary are annotated with 'PA' (and often 'SP') and require prior authorization before coverage — examples in the list include ARIKAYCE, KITABIS PAK, TOBI PODHALER and posaconazole/CRESEMBA formulations.
- Follow the product line Requirements/Limits and obtain PA for the listed inhaled antimicrobials and antifungal agents prior to dispensing.
PA (and SP) required for select HCV DAAs
Hepatitis C direct-acting antivirals such as EPCLUSA, HARVONI, SOVALDI, MAVYRET and VOSEVI are shown with Requirements/Limits = PA and SP and therefore require prior authorization (and specialty routing) before coverage.
- Submit PA requests for these DAAs and route through specialty pharmacy if indicated on the product line.
Obtain PA and follow QL for oncology/specialty agents
Many oncology and specialty agents list Prior Authorization (PA) and Quantity Limits (QL) on the drug line; an approved PA must be in place before dispensing and the dispensed quantity must not exceed the stated QL.
- Obtain PA for oncology/specialty entries marked 'PA' and adhere to the per-product QL (e.g., specified tablets, capsules, vials per time period).
PA required when 'PA' is indicated
Any drug line explicitly marked with Requirements/Limits = PA requires an approved prior authorization before the plan will cover the medication.
- Do not dispense expecting coverage without first securing the PA for products labeled 'PA'.
PA required for select endocrine/GLP‑1 and reproductive agents
Several commonly used agents are noted with 'PA' on their formulary lines — examples include MYFEMBREE, ORIAHNN, MOUNJARO, OZEMPIC and RYBELSUS — and coverage requires prior authorization as indicated.
- Submit PA supporting documentation for these products prior to dispensing; QL noted on lines (e.g., MYFEMBREE QL 30/30 days; ORIAHNN QL 56/28 days).
PA required per product-level Requirements/Limits
Certain agents in the diabetes, endocrine and specialty sections are annotated with PA (and sometimes SP); when PA is listed an authorization must be obtained before coverage is allowed (examples include OZEMPIC, TRULICITY, ACTHAR, GENOTROPIN).
- Follow the Requirements/Limits on each product line and obtain PA and specialty pharmacy routing where 'SP' is present.
Comply with step therapy or request exception
Step therapy (ST) may be applied to some drugs and generally requires trial of a first‑line preferred medication before coverage of the later‑step drug; prescribers may request a step therapy exception if the preferred agent is not clinically appropriate.
- If a product shows 'ST' on the formulary line, document prior trial(s) of required agents or submit a step therapy exception per the payer process.
Follow per‑product step/utilization flags and QL
Some formulary entries include flags such as NM, AC and QL and show quantity limits that reflect utilization controls; follow the per‑product Requirements/Limits noted on the drug line when prescribing and dispensing.
- Check each product's Requirements/Limits for NM/AC/QL indicators and comply with documented limits or obtain authorization/exception as needed.
No explicit step‑therapy sequence in this excerpt
The document excerpt does not include explicit multi‑step sequences for most products; many entries only show tier, PA/AC/NM and QL flags without a detailed step hierarchy.
- For products without explicit ST sequencing, follow the payer's PA and exception processes as applicable.
Document trials or request exception for 'ST' drugs
Some drugs are explicitly annotated with 'ST' on the formulary line (for example KERENDIA), indicating a step therapy requirement applies and prescribers must document trial/failure or obtain an exception per plan rules.
- When 'ST' is listed, include documentation of prior therapy trials or submit a step therapy exception request.
How to submit PA/exception requests
Submit prior authorization, step therapy exception, or coverage exception requests by calling the number on the member's ID card (or using the payer's forms); decisions are communicated within the timelines specified in the Exception Process (standard and expedited).
- Standard requests: decision within three business days.
- Expedited requests: decision within 24 hours when applicable.
Adhere to PA/QL/SP flags on drug lines
Follow the Requirements/Limits flags on each formulary line (PA, QL, NM, AC, SP); these flags indicate the administrative controls that must be met for coverage and dictate whether PA, specialty routing, or quantity adherence is required.
- Check the product line for PA, QL, SP and other flags before prescribing or dispensing.
Denial risk if PA not obtained
When a product line shows 'PA', an approved prior authorization is required before the plan will cover the medication; claims submitted without required PA for PA‑listed products risk denial at adjudication.
- Do not assume coverage for PA‑flagged drugs without an approved PA; claim denials may result if PA is not obtained.
Initial coverage & starter/titration rules
Initial therapy — follow per-product flags
Initial therapy coverage is determined by the per‑product Requirements/Limits flags present on the formulary line; detailed clinical initiation criteria are not provided in this excerpt.
No product‑specific clinical eligibility criteria for initiation are included in these chunks; the flags indicate administrative controls to follow.
Initial therapy utilization controls
Utilization controls at therapy initiation include prior authorization and quantity limits for select products.
Providers must submit PA documentation and adhere to QL for initial fills as annotated per product.
INITIAL THERAPY CRITERIA
Initial dispensing is limited where quantity limits are specified on product lines.
Exact QL values vary by product — use the product line entry for the precise limit.
Starter / titration products
Titration, starter and therapy packs are identified where applicable and carry the same administrative controls as their maintenance counterparts.
No additional clinical initiation criteria for starter/titration kits are provided in this excerpt.
Renewal / continuation rules
Step therapy rules & affected products
| Step therapy rule | Details / provider action |
|---|---|
| Try preferred first-line medication before coverage for later-step drug (Step Therapy / ST) | |
| If the preferred first-line drug is not appropriate, prescriber may submit a step therapy exception request per the exception process noted in the policy; step therapy presence is typically flagged with 'ST' next to the medication. |
| Annotation | Implication for utilization management |
|---|---|
| NM (Not Medically Necessary) | |
| Products annotated 'NM' indicate special medical-necessity handling or potential non-covered formulations; coverage depends on meeting the payer's requirements or may be denied. | |
| AC (Administrative Condition) | |
| 'AC' denotes administrative/access controls that must be satisfied per payer process before coverage is approved. | |
| QL (Quantity Limit) | |
| 'QL' specifies a dispensing/quantity limit (e.g., tablets or mLs per time period) that must be adhered to or an authorization requested for larger quantities. |
| Step therapy sequencing present? | Notes |
|---|---|
| No explicit step-therapy sequences defined | |
| The excerpt lists tiers and utilization flags (PA, QL, NM, AC, SP) but does not provide multi-step algorithms or required prior agents; where step therapy applies it is flagged 'ST' on the product line. |
| Products marked ST | Summary / availability of specific step details |
|---|---|
| KERENDIA (finerenone) — Requirements/Limits show QL (30 tablets/30 days), ST | |
| Entry indicates a step therapy requirement applies (ST) but this section does not include the specific required prior agent(s) or failure criteria; follow payer step-therapy exception process. |
| Titration / starter packs | Step therapy sequencing included? |
|---|---|
| UPTRAVI TITRATION PACK; TYVASO TITRATION/STARTER KIT; other therapy packs listed | |
| Titration/therapy packs are provided for initial dosing and have QL/PA flags, but explicit step-therapy sequences or failure criteria for progressing between steps are not detailed in this excerpt. |
| Products with ST edits (examples) | Plan implication |
|---|---|
| FETZIMA — Requirements/Limits = BH, ST | |
| Step therapy edits apply; prescriber must document trial/failure or contraindication to required prior agents or request a step-therapy exception as applicable under plan rules. | |
| FANAPT TITRATION PACK / FANAPT — Requirements/Limits include BH, QL (1 pack/180 days), ST | |
| Titration packs and FANAPT are subject to step therapy edits per the formulary; specific prior-step agents and sequencing are not specified here — follow the payer's ST and exception procedures. |
Per-product quantity limits and examples
Specialty pharmacy, infusion and medical benefit routing
Background & scope
Specialty drugs are medications used to treat complex or chronic conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis. They may be oral, topical, or injectable and can be self‑administered or given by a healthcare professional. Drug selection for the formulary is made by a physician/pharmacist committee and is based on FDA approval, clinical effectiveness, safety, and cost. Many specialty therapies listed in the Drug List are subject to utilization controls (for example PA, QL, or SP) and may be covered under the pharmacy or medical benefit depending on site of care and administration.
Abbreviations, tiering & flags
Biosimilar & insulin notes
Document updates
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