CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Programs for Members on the Performance Drug List

This document lists prescription drugs and categories on the payer's Performance Drug List that are subject to prior authorization for Blue Cross Blue Shield - New Mexico members. It enumerates drug categories and many specific drug names grouped into categories or tiers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Programs for Members on the Performance Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders should reference the Performance Drug List and initiate prior authorization or an exception review via the member ID card phone number or the provider website when prescribing listed medications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+drug category headings present in this partial extract

hundredsindividual drug names listed (partial document)

multi-tiersome categories show tier/level distinctions

state-specificpayer

contact required

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Coverage Criteria Overview

This document lists medications and categories included on Blue Cross Blue Shield of New Mexico’s Performance Drug List that are subject to utilization review. If a medication is not included on the Drug List, members or their prescribers may request an exception review. Exception requests are evaluated against the drug’s applicable prior authorization program criteria and may require that those criteria be met before coverage is approved.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Medications and drug categories on Blue Cross Blue Shield - New Mexico's Performance Drug List require prior authorization. The Performance Drug List is a reference roster providers should consult when determining whether a PA is required for a prescription.

The Performance Drug List groups medications into tiered categories (noted here as "1 =" and "2 =") that indicate preferred vs alternative products within a therapeutic category; prescriptions inconsistent with the tier placement may require additional review or be denied without an approved exception.
Many entries list both Therapeutic Alternatives and Supplemental Therapeutic Alternatives — these identify preferred alternatives that may be requested or required during prior authorization or step-therapy reviews.
Example category/brand mappings (illustrative, not exhaustive): Xolair and Xolremdi are shown together as category examples; GLP-1 agonists are grouped with 1 = (e.g., Bydureon Bcise, Byetta) and 2 = (e.g., Ozempic, Rybelsus), demonstrating the tiered grouping behavior.
Prior authorization program criteria must be met for drugs on the Performance Drug List. If the prescriber or member requests an exception review, the request may be denied if PA program criteria are not satisfied.
To initiate a prior authorization or exception review, call the phone number on the member's ID card or ask the prescribing provider to start the review at bcbsnm.com/provider.

Denial Risk

Performance Drug List — PA & Tier Notes

Prescriptions for medications listed on the Performance Drug List are subject to the PA program. The listing functions as the operational roster for PA determination and includes tier annotations, therapeutic alternative guidance, and example brand-to-category mappings.

The document lists drugs and categories that require prior authorization — providers must verify PA requirements before dispensing.
Tier designation reference: many categories use numeric tiers (e.g., "1 =", "2 =") to indicate preferred vs alternative products; this tiering may guide coverage decisions and exception handling.
Tier-based prior authorization / potential denial: prescriptions that do not meet the tier or PA criteria may be denied unless an approved exception is granted.
Denial risk: during an exception review, if the member or prescriber does not meet the stated PA program criteria, the request may be denied.

Step Therapy

Tiered Groupings & Therapeutic Alternatives

Where the Performance Drug List shows grouped entries (for example GLP-1 agonists: 1 = Bydureon Bcise, Byetta; 2 = Ozempic, Rybelsus), these groupings indicate preferred versus alternative agents and imply possible step-therapy sequencing though no explicit step-therapy rules are listed here. Therapeutic Alternatives and Supplemental Therapeutic Alternatives entries identify drugs typically considered before non-preferred options.

Tiered groupings are used across many categories to delineate preferred (1) and alternative (2) medications.
Therapeutic Alternatives and Supplemental Therapeutic Alternatives identify agents that may be preferred during prior authorization or step reviews.
Example mappings are included in the list to help prescribers identify which branded products map to a given category; these are examples and not an exhaustive rule set.

Note

How to Initiate Review

Operational notes for initiating review and contacting the plan.

If you have questions or to begin a prior authorization/exception review, call the number on the member ID card.
Providers may also request a prescriber-initiated review at bcbsnm.com/provider.
These programs and the listed drugs are subject to change; additional drugs may be added to categories over time.

Background and Scope

The extract is an administrative roster of drug categories and example product listings used to identify medications that may be subject to prior authorization. It does not contain clinical coverage criteria, indications, dosing, or step-failure rules in this portion; rather, it provides examples of categories and specific drugs and directs providers and members to initiate an exception review or prior authorization through the contact information on the member’s ID card or the provider website.

Definitions & Document Conventions

Tier/group indicators

1 =Denotes the first-tier or preferred agents within a category (examples: Bydureon BCise, Byetta, Exenatide, Liraglutide, Mounjaro, Genotropin, Humatrope, Norditropin Flexpro, Ngenla, Hemlibra, AlphaNine SD, Harvoni, Ledipasvir/Sofosbuvir, Mavyret, Sofosbuvir/Velpatasvir, Andembry, Berinert, Cinryze, Dawnzera, Qbrexza, iLet Bionic Pancreas, Omnipod DASH pods)

2 =Denotes the second-tier or alternative/non-preferred agents within a category (examples: Ozempic, Rybelsus, Trulicity, Saizen, Serostim, Skytrofa, Ixinity, Profilnine SD, Rebinyn, Sovaldi, Viekira Pak, Viekira XR, Vosevi, Firazyr/icatibant, Haegarda, Orladeyo, Ruconest, Sofdra, Vyleesi)

PurposeUsed to separate drugs within a category to indicate preferred (1) versus alternative/non-preferred (2) agents for the Performance Drug List grouping

Provider action implicationMedications annotated with 1 or 2 should be referenced by tier when requesting prior authorization; inconsistent prescribing relative to the listed tier may risk denial

Step Therapy / Tier Grouping Details

Grouping label	1 = (preferred / tier 1)	2 = (alternative / tier 2)
{"text":"GLP-1 (glucagon-like peptide-1) Agonists","status":""},{"text":"Bydureon BCise; Byetta; Exenatide; Liraglutide","status":""},{"text":"Ozempic; Rybelsus; Trulicity","status":""}
{"text":"Growth Hormone (formerly Growth Hormone/ Egrifta)","status":""},{"text":"Mounjaro; Genotropin; Humatrope; Norditropin Flexpro; Ngenla","status":""},{"text":"Saizen; Serostim; Skytrofa","status":""}
{"text":"Interleukin-4 Inhibitors (formerly Injectable Atopic Dermatitis)","status":""},{"text":"Dupixent","status":""},{"text":"","status":""}
{"text":"Interleukin-5 Inhibitors","status":""},{"text":"Fasenra","status":""},{"text":"Nucala","status":""}
{"text":"Therapeutic Alternatives (example)","status":""},{"text":"Absorica/Absorica LD; Adapalene","status":""},{"text":"Konvomep suspension; Lexette","status":""}
{"text":"Somatostatins (formerly Somatostatin Analogs)","status":""},{"text":"Bynfezia","status":""},{"text":"Palsonify; Somavert","status":""}

Therapeutic Alternatives group	1 = (preferred / listed as 1)	2 = (supplemental / listed as 2)
{"text":"Supplemental Therapeutic Alternatives","status":""},{"text":"Daraprim","status":""},{"text":"Rytary","status":""}
{"text":"Therapeutic Alternatives (acne-related examples)","status":""},{"text":"Absorica/Absorica LD; Adapalene","status":""},{"text":"Konvomep suspension; Lexette","status":""}
{"text":"Sohonos","status":""},{"text":"Sohonos","status":""},{"text":"","status":""}

Example drug	Mapped category / Performance Drug List value	Notes
{"text":"Xolair","status":""},{"text":"Xolair / Xolremdi (paired in multiple example mappings)","status":""},{"text":"Document shows repeated brand-to-category mapping examples pairing Xolair with Xolremdi","status":""}
{"text":"Xolremdi","status":""},{"text":"Xolair / Xolremdi (paired in multiple example mappings)","status":""},{"text":"Entries repeat across chunks indicating illustrative mappings, not explicit step rules","status":""}
{"text":"Zelsuvmi","status":""},{"text":"Zelsuvmi (mapped to Yorvipath)","status":""},{"text":"Shown as 'Zelsuvmi, Yorvipath = Zelsuvmi' in source","status":""}
{"text":"Zeposia","status":""},{"text":"Zeposia (mapped to Yorvipath)","status":""},{"text":"Shown as 'Zeposia, Yorvipath = Zeposia' in source","status":""}
{"text":"Zokinvy","status":""},{"text":"Zokinvy (mapped to Yorvipath)","status":""},{"text":"Shown as 'Zokinvy, Yorvipath = Zokinvy' in source","status":""}
{"text":"Zoryve","status":""},{"text":"Zoryve (mapped to Yorvipath)","status":""},{"text":"Shown as 'Zoryve, Yorvipath = Zoryve' in source","status":""}