Blue Cross Blue Shield NM Prior Auth/Step Therapy Policy

Coverage Criteria

General prior authorization coverage criteria

Covered when ALL of the following are met

Program-level requirements: Request is for a target drug listed in the program and documentation supports use according to product labeling, clinical guidelines, compendia, or clinical studies; dosing follows product labeling

Developed by clinical team of physicians and pharmacists

Alternative Dosage Form criteria

Covered when ALL of the following are met

Alternative Dosage Form: Prescriber documents that the oral solid dosage form is not clinically appropriate for the patient (program is not applicable to children ≤12 years of age)

Prescriber must provide documentation that oral solid dosage form is not clinically appropriate

Hepatitis C DAA criteria

Covered when ALL of the following are met

Hepatitis C DAAs: Member meets program criteria and use of the preferred direct-acting antiviral by genotype is typically required before coverage of non-preferred products; dosing must follow product labeling

Genotype-based preferred agent use encouraged/required

General PA/Step Therapy Criteria

Coverage for listed drugs is governed by program intents which generally require:

General PA/Step requirements: Therapy selection should align with product labeling and/or clinical guidelines/compendia/clinical studies and dosing should follow product labeling; step therapy items encourage use of preferred or formulary alternatives before nonpreferred/brand/ER agents when clinically appropriate

Applies across listed entries unless a specific program provides additional detail.

General Step Therapy Coverage Criteria

Covered when the following program intents are satisfied for each category

General step therapy logic: Use formulary, preferred, or cost-effective generic agent prior to non-formulary/nonpreferred or brand agents as specified per category unless not clinically appropriate; follow product labeling dosing.

Applies per listed category (examples include Colony Stimulating Factors, DPP-4 inhibitors, Gabapentin ER, Insomnia agents, SGLT inhibitors, topical NSAIDs, ophthalmic prostaglandins, etc.)

The Growth Hormone program excludes the use of recombinant growth hormone for Idiopathic Short Stature (ISS). ISS is explicitly not included among indications allowed in product labeling for the listed growth hormone agents and therefore is not an allowed indication under this prior authorization program.

Topical and oral agents for onychomycosis are managed by prior authorization and the program discourages cosmetic utilization. Requests should document a medically indicated diagnosis and adherence to product labeling or guideline-based indications rather than treatment for purely cosmetic reasons.

As noted in the onychomycosis program intent, the utilization management approach is intended to select patients according to labeling and clinical guidance and explicitly discourages cosmetic use of onychomycosis therapies.

Not every drug category or step therapy program described in this document applies to every member. Coverage and program applicability depend on the member's specific pharmacy benefit and drug list. Providers should verify benefit inclusion in the member's plan using the member materials or the phone number on the member ID card; the infertility step therapy program does not apply to standard HMO plans.

Use of a drug for an indication that is not included in the product labeling is not permitted under the program. For example, treatment of Idiopathic Short Stature (ISS) with growth hormone is not an allowed indication because ISS is not included in the agents' product labeling.

Coding and Target Drugs

Continuous Glucose Monitor target devicesmixed

Dexcom G6	Continuous Glucose Monitor - Dexcom G6 CGM System
Dexcom G7	Continuous Glucose Monitor - Dexcom G7 CGM System
Freestyle Libre	Continuous Glucose Monitor - Freestyle Libre series

GLP-1 Agonistsmixed

Bydureon Bcise	GLP-1 agonist - Bydureon Bcise
Byetta	GLP-1 agonist - Byetta
Mounjaro	GLP-1 agonist - Mounjaro
Ozempic	GLP-1 agonist - Ozempic

Multiple Sclerosis Target Drugsmixed

Aubagio	target drug listed under Multiple Sclerosis prior authorization
Kesimpta	target drug listed under Multiple Sclerosis prior authorization
Tecfidera	target drug listed under Multiple Sclerosis prior authorization

Onychomycosis Target Drugsmixed

Ciclopirox	Onychomycosis target drug
Jublia	Onychomycosis target drug
Kerydin	Onychomycosis target drug
Sporanox	Onychomycosis target drug

Antidepressants — Step Therapy Target Drugsmixed

Auvelity	Antidepressant target drug under step therapy
Cymbalta	Antidepressant (also used for neuropathic pain) targeted in step therapy

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for many of the drug categories listed below and for each listed target drug or drug class. Coverage is permitted only when the conditions of the applicable prior authorization or step therapy program are met; failure to meet program criteria or to obtain required authorization may result in denial of coverage.

Prior authorization and step therapy programs are developed by a clinical team using FDA labeling, clinical guidelines, and the medical literature.
Providers should call 800-285-9426 to confirm the status of a particular drug or to verify whether a category or specific drug is included in a member's benefit.
If a category is not included in the member's pharmacy benefit or is restricted on the member's drug list, the program will not apply — verify applicability by checking member materials or calling the phone number on the member's BCBSNM ID card.

Prior Authorization

Multiple Sclerosis — Prior Authorization

Multiple sclerosis therapies listed under the Multiple Sclerosis category require prior authorization to ensure appropriate patient selection and dosing consistent with product labeling and clinical guidelines.

Background

This prior authorization and step therapy program is designed to promote safe, clinically appropriate, and cost‑effective medication use by aligning prescribing with FDA product labeling, clinical guidelines, compendia, and clinical studies. A multidisciplinary clinical team of physicians and pharmacists develops program intents and coverage requirements to ensure appropriate patient selection and dosing consistent with product labeling.

Definitions

Children — definition

DefinitionChildren = members 12 years of age and under (specified in the Alternative Dosage Form program).

ContextApplied to the Alternative Dosage Form prior authorization program which exempts this group from the requirement to trial oral solid dosage forms.

Implication for prescribersFor members ≤12 years, the Alternative Dosage Form program’s prescriber documentation requirement about oral solid dosage forms does not apply.

Program Intent — purpose and scope

Primary purposeProgram intent: to help appropriately select patients for therapy according to product labeling, clinical guidelines, and/or clinical studies and to ensure dosing follows product labeling.

Alternative Dosage Form intentEncourage use of more cost‑effective oral solid dosage forms prior to alternative formulations; requires prescriber documentation that oral solids are not clinically appropriate (except for children ≤12).

Initial Therapy Preferences

Per-category initial therapy preference

Per-category preferred-first rule: Each listed category encourages use of a formulary/preferred or cost-effective generic agent prior to nonpreferred or non-formulary products, unless not clinically appropriate; follow product labeling dosing.

Examples: use preferred glucose test strips before nonpreferred; use generic immediate‑release gabapentin before ER formulations; use formulary colony stimulating factor prior to non‑formulary agents; use antidiabetic or ACE/ARB before Kerendia.

Step Therapy Details

Drug category / example	Step therapy requirement	Notes
Biologic immunomodulators (e.g., adalimumab, etanercept, ustekinumab)
Encourage trial of first-line agents prior to use of preferred biologic immunomodulators
Program intent: select patients per product labeling/guidelines; encourages use of first-line agents prior to preferred biologics

Drug category / example	Step therapy requirement	Notes
Antidepressants (examples: Auvelity, Cymbalta, Celexa, Sertraline)
Encourage use of preferred generic antidepressants prior to new prescriptions for brand agents
Applies to new prescriptions; allows brand use when generics are not clinically appropriate; follows product labeling dosing

Drug category / example	Step therapy requirement	Notes
Gabapentin ER products (Gralise, Horizant)
Encourage trial of cost-effective immediate‑release generic gabapentin prior to ER formulations
Applies unless immediate‑release gabapentin is not clinically appropriate; dosing per product labeling

Drug category / example	Step therapy requirement	Notes
Colony stimulating factors (examples: Neupogen, Granix, Fylnetra, Udenyca)
Encourage use of a formulary agent prior to use of non‑formulary colony‑stimulating factors
If formulary agent is not clinically appropriate, non‑formulary may be considered; follow product labeling dosing

Drug category / example	Step therapy requirement	Notes
DPP‑4 inhibitors, Ophthalmic prostaglandins, Insomnia agents, SGLT inhibitors, Topical NSAIDs, etc.
Encourage use of preferred/formulary or cost‑effective generic agents prior to nonpreferred/non‑formulary agents
Applies per listed category unless not clinically appropriate; follow dosing recommended in product labeling

OpenPayer

Prior Authorization/Step Therapy Program — Pharmacy

Coverage Criteria

Coding and Target Drugs

Provider Actions and Authorization Requirements

Background

Definitions

Initial Therapy Preferences

Step Therapy Details