CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2026 Drug List — Pharmacy & Specialty Drugs (Formulary, Utilization Controls, and Prior Authorization Guidance)

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.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List — Pharmacy & Specialty Drugs (Formulary, Utilization Controls, and Prior Authorization Guidance)

Policy CodePolicy N/A

Change TypeNo material change reported

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line lists 'PA' before dispensing to ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120distinct drug entries in this excerpt

Multiple PA & QLutilization management rules present

SP notedspecialty pharmacy designated

Includednon-discrimination & language assistance

30/90

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common supply durations

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.

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intro':'Product-level coverage annotations — Coverage stance is shown per product using Drug Tier and Requirements/Limits flags.','title':'Formulary coverage indicators','type':'criteria_group'},{

nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Representative product-level entries (selected examples) are shown to illustrate how products appear on the formulary and the kinds of administrative requirements that may apply.\"},{\"text\":\"AMOXICILLIN (multiple formulations) — Drug Tier = NP or p depending on formulation; Requirements/Limits = none for many oral formulations.\"},{\"text\":\"AZITHROMYCIN — Drug Tier ranges (np/p); Requirements/Limits examples include NM and QL (e.g., QL 60 tablets/180 days for some strengths).\"},{\"text\":\"TOBRAMYCIN/ARIKAYCE — Many inhaled/novel formulations carry Requirements/Limits including PA, QL (e.g., 280 mls/56 days), and SP (specialty).\"},{\"text\":\"XIFAXAN (rifaximin) — multiple strengths with QL restrictions (e.g., 9 tablets/30 days for 200 mg; 126 tablets/365 days for 550 mg).\"},{\"text\":\"VANCOMYCIN (oral) — oral capsule and solution entries show Drug Tier = np with QL on capsules (e.g., QL 120 capsules/30 days).\"}]}"],

intro':'Product-level coverage entries — Coverage entries and common constraints (selected examples)','title':'Product-level coverage entries','type':'criteria_group'},{"nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Vaccines and biologicals on the formulary include Drug Tier = P for most entries and Requirements/Limits such as AC (age/clinical criteria) and NM (state-specific limitations).\"},{\"text\":\"Examples: COMIRNATY (COVID-19) entries show Requirements/Limits = AC, NM; many influenza and pediatric vaccines show AC or no additional limits.\"},{\"text\":\"Vaccine entries noted with NM may be limited for certain indications or populations per New Mexico-specific rules — check benefit materials.\"}]}"],

intro':'Vaccines & Biologicals — coverage flags and vaccine-specific restrictions','title':'Vaccines & biologicals coverage annotations','type':'criteria_group'},{"nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Antineoplastics, specialty and oncology agents frequently require Prior Authorization (PA), Quantity Limits (QL), and are often designated as specialty (SP).\"},{\"text\":\"Examples: ALECENSA, ALUNBRIG, AYVAKIT, BOSULIF, BRUKINSA and many others are listed with PA, QL (specific tablet/capsule limits per time period), and SP where applicable.\"},{\"text\":\"When PA is indicated, supporting clinical documentation and diagnosis consistent with FDA labeling or evidence-based guidelines is typically required.\"}]}"],

intro':'Antineoplastics & specialty agents — utilization controls','title':'Antineoplastics & specialty coverage rules','type':'criteria_group'},{"nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Other anti-infectives and miscellaneous agents are annotated with Drug Tier and Requirements/Limits; examples include linezolid, nitrofurantoin, metronidazole, sulfamethoxazole-trimethoprim, rifaximin and others.\"},{\"text\":\"Selected constraints: linezolid oral suspension/tab may have QL (e.g., 600 mls/180 days or 56 tablets/180 days); nitazoxanide has QL (6 tablets/30 days).\"},{\"text\":\"Certain products show NM (state-specific), PA, or other flags depending on formulation and clinical use.\"}]}"],

intro':'Antimicrobials & miscellaneous agents — coverage annotations','title':'Antimicrobials & miscellaneous coverage','type':'criteria_group'},{"nodes":["{\"operator\":\"all\",\"children\":[{\"text\":\"Formulary line rules: each product row indicates the Drug Tier and any Special Requirements/Limits; those flags govern administrative actions at point of dispense.\"},{\"text\":\"Operational items to watch for: prior authorization submission when 'PA' is present; step therapy exception requests when 'ST' is present; adherence to QL limits to avoid member financial responsibility.\"},{\"text\":\"When a product is marked SP (specialty), it may be handled through a specialty pharmacy channel and subject to additional dispensing rules.\"}]}"],

intro':'Formulary line coverage rules — operational notes','title':'Formulary line coverage rules','type':'criteria_group'}],

id':'coverage-criteria','label':'COVERAGE CRITERIA','title':'Formulary coverage & per-product rules' }**INVALID**}espit to ensure valid JSON. The output must be valid JSON only.

Billing / code references and quantity-limit examples

Prior authorization, step therapy, documentation & denial risks

Prior Authorization

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.

Prior Authorization

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.

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.

Initial prescribing: When initiating therapy, prescribers must follow the product's listed Requirements/Limits (PA, QL, ST, SP, AC, NM) shown on the formulary line; obtain required prior authorization and comply with quantity limits and specialty routing where indicated.

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.

Initial PA/QL requirements: Certain products require prior authorization (PA) at initiation and have defined quantity limits (QL) for the initial fill (examples in this excerpt include ORIAHNN, MYFEMBREE, MOUNJARO, OZEMPIC, RYBELSUS).

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

inv-181: various (see drug list)

Typical periodsPer prescription or time period as specified (commonly 30-day supply; some 90-day maintenance limits).

Variation by productSome products use 28-, 56-, 180-, or 365-day windows depending on formulation and indication.

ActionConfirm the exact QL entry on the product line prior to dispensing or requesting authorization.

inv-182: azithromycin tab 250 mg / 500 mg

Azithromycin tabs60 tablets (azithromycin tab 250 mg / 500 mg)

ContextListed with Requirements/Limits = NM and QL (60 tablets/180 days) for oral tablet strengths.

Specialty pharmacy, infusion and medical benefit routing

Note

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.

inv-112: Specialty drugs definition and administration notes

Specialty drugs definedOral, topical, or injectable medications used for complex conditions; some administered by health care professionals and may be covered under medical rather than pharmacy benefit.

ManagementSpecialty products are often marked 'SP' and may require specialty pharmacy distribution and prior authorization.

Where to checkFor current specialty medication list and coverage details visit MyPrime.com or bcbsnm.com.

Abbreviations, tiering & flags

inv-113: Drug list formatting & tier notation

Formatting conventionsGenerics shown in lower-case bold; brands in ALL CAPS; preference markers include 'p', 'np', 'P', 'NP', and 'SP' as annotated in product lines.

Tier meaningTier markings indicate plan-specific preference and member cost-share (see plan materials for exact benefit levels).

Specialty notationProducts managed under specialty programs are additionally marked 'SP' in the Special Requirements column.

inv-117: PA / AC / NM / QL / SP

PAPrior Authorization — an approved authorization required before coverage when 'PA' is listed in Requirements/Limits.

ACAdministrative Condition / Authorization Code — administrative criteria may apply for coverage (appears for some contraceptives and other agents).

Biosimilar & insulin notes

Note

Document updates

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List — Pharmacy & Specialty Drugs (Formulary, Utilization Controls, and Prior Authorization Guidance)

Policy CodePolicy N/A

Change TypeNo material change reported

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization when a drug line lists 'PA' before dispensing to ensure coverage.

SourceLink

On This Page

Prior Authorization

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.

Prior Authorization

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).

Prior Authorization

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'.

Prior Authorization

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).

Prior Authorization

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.

Step Therapy

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.

Note

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.

Note

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.

Step Therapy

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.

Documentation Required

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.

Documentation Required

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

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.

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.

Initial dispensing limits: When a QL is listed on the formulary line, initial fills are limited to the stated quantity and time period (for example: 1 pen/28 days for OZEMPIC; 4 pens/28 days or 4 pens/180 days for certain MOUNJARO entries; 100 mls/30 days for many insulin products).

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.

Starter/titration products: Designated starter or titration kits (for example UPTRAVI TITRATION PACK, TYVASO TITRATION/STARTER KIT, TYVASO DPI MAINTENANCE KI) are listed with Requirements/Limits including PA, QL and SP; these are intended for initial/titration use and coverage follows the product annotations.

No additional clinical initiation criteria for starter/titration kits are provided in this excerpt.

See macrolides section for azithromycin tablet QL entries.

inv-183: clarithromycin tab er 24hr 500 mg

Clarithromycin ER 500 mg28 tablets (clarithromycin tab ER 24hr 500 mg)

NotationEntry lists QL (28 tablets/180 days) for the ER 500 mg formulation.

Therapeutic classListed under macrolides in the formulary lines.

inv-184: itraconazole cap and oral soln

Itraconazole limits120 capsules / 1200 mls (itraconazole cap and oral soln)

Forms coveredBoth capsule (120 capsules/30 days) and oral solution (1200 mls/30 days) QLs are specified in product lines.

RequirementCheck product line for NP tiering and any PA flags that may apply to antifungals.

inv-185: ARIKAYCE

ARIKAYCE QL28 vials (QL 28 vials/28 days)

ClassAmikacin liposome inhalation suspension listed under aminoglycosides with PA, QL and SP flags.

Provider notePrior authorization and specialty routing apply; verify PA before dispensing.

inv-186: TOBI PODHALER

TOBI PODHALER QL224 capsules (QL 224 capsules/56 days)

NotesListed as a specialty inhalation product with PA and SP annotations.

Dispensing window56-day QL window applies as shown on product line.

inv-187: TOBRAMYCIN nebu soln

Tobramycin nebu soln QL280 mls (QL 280 mls/56 days)

FormulationNebulized solution listed with PA, QL and SP where applicable.

ActionObtain prior authorization for specialty inhaled antimicrobials when flagged.

inv-188: various

Various QL formats30 tablets/30 days; 28 packs/28 days; 90 tablets/30 days; 4 tablets/365 days; mLs limits for suspensions (e.g., 600 mls/180 days)

InstructionExact QL is shown on each product line—refer to the drug entry for the precise amount and period.

Examples across classesQLs appear for antibiotics, antivirals, insulins, and specialty agents in varied units (tablets, packs, mLs, pens).

inv-199: OZEMPIC — 1 (pen/30 days)

OZEMPIC1 pen/28 days

RequirementEntry lists PA and QL (1 pen/28 days) for semaglutide pens as noted in formulary lines.

Provider actionObtain PA when indicated and adhere to the per-pen QL at dispensing.

inv-200: RYBELSUS (3 mg and higher strengths) — 30

RYBELSUS (≥3 mg)30 tablets (QL 30 tablets/30 or 180 days depending on strength)

FormsOral semaglutide strengths have strength-dependent QL windows (see product line for 30/30 vs 30/180 distinctions).

PA flagRYBELSUS entries list PA with QL as indicated per strength.

inv-207: REPATHA — 6

REPATHA quantity6 (QL 6 syringes/28 days)

NotesREPATHA entries show PA and QL and are managed as specialty products in many cases.

DispensingLimit applies per 28-day period for syringes or pens as listed.

inv-217: TRIKAFTA — 56 packets/28 days

TRIKAFTA56 packets/28 days

Specialty designationTRIKAFTA requires PA and is managed as a specialty product (SP) per formulary entries.

Dispensing windowPer-packet QL applies over 28-day period as shown.

inv-231: wegovy (semaglutide) pens — 8 pens

wegovy pens8 pens (QL 8 pens/180 days)

Alternative packSome Wegovy packings show QL 4 pens/28 days for different strengths—verify listed pack and window.

PA requirementWegovy entries include PA and QL flags in the formulary lines.

inv-232: zepbound (tirzepatide) pens 2.5 mg — 4 pens

Zepbound 2.5 mg pens4 pens (QL 4 pens/180 days)

IndicationWeight-management tirzepatide listings include PA and QL per strength/pack.

Dispensing noteSome strengths have alternate QL windows (4 pens/28 days) — confirm per line.

inv-240: tramadol ER and tramadol — QL examples

Tramadol QLsTramadol ER: QL 30 tablets/30 days; Tramadol 50 mg (IR): QL 240 tablets/30 days

ReferenceListed under analgesics with explicit QL entries per formulation (ER vs immediate-release).

Dispensing impactPrescriptions exceeding QL may require PA or result in member responsibility for excess quantity.

NMNot Medically Necessary — indicates formulations or uses that may be considered not medically necessary for coverage.

QLQuantity Limit — maximum quantity permitted in the specified time period, shown as 'QL (amount/time)'.

SPSpecialty — product managed through specialty pharmacy with potential additional handling and PA requirements.

inv-122: SP — Specialty designation

SPSpecialty — product managed under specialty pharmacy programs or requires special handling; marked 'SP' on product lines.

ImplicationSP-designated drugs frequently require prior authorization and specialty distribution channels.

ExamplesMultiple antineoplastics, cystic fibrosis modulators, and biologics in the list carry 'SP' annotations.

inv-134: Drug Tier (P/NP/P+ etc.)

Drug TierPlan-specific tier codes indicate coverage level/preferred status (e.g., P = Preferred, NP = Non-Preferred, P+ = higher preferred).

UseTier affects member cost-share and may influence step therapy or PA requirements.

Notation sourceTier markers are shown next to each drug in the formulary lines as described in formatting conventions.

inv-147: ST — Step Therapy

ST (Step Therapy)Step Therapy — requirement to try a first-line preferred medication before coverage for the listed drug; marked 'ST' where applicable.

Exception processPrescribers can request step therapy exceptions if the preferred agent is not appropriate for the patient.

DocumentationWhen 'ST' is listed, prescribers must document prior trial/failure or contraindication to required agents per plan rules.