CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2026 Drug List (Formulary) - Blue Cross and Blue Shield of New Mexico

Statewide pharmacy drug list/formulary describing covered prescription drugs, tier placements, special requirements (PA, ST, QL, AC, BH, NM, SP), dispensing limits, specialty pharmacy arrangements, exception processes, and member/provider instructions. Lists therapeutic classes and numerous specific drugs with tiers and requirements/limits.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List (Formulary) - Blue Cross and Blue Shield of New Mexico

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests for medications flagged 'PA' and follow the payer's exception and specialty pharmacy procedures as noted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported for this policy part (has_material_change=false).

~200+Drugs listed in this part

manyProducts with PA

multipleProducts with QL

severalSpecialty pharmacy (SP) products

1Specialty vendor (Accredo)

Coverage Summary

General Coverage and Special Requirements

Covered drugs are those listed on the BCBSNM 2026 Drug List. Drugs not shown on that list are not covered. Some medications may be covered under the medical benefit rather than the pharmacy benefit (for example, provider-administered products); specialty drugs may appear on a separate Specialty Drug List. Effective date: 2026-01-01. Last review: January 2026.

Covered drugs must be listed on the BCBSNM 2026 Drug List to be eligible under this pharmacy benefit.

Prior Authorization (PA), Step Therapy (ST), Quantity Limits/Dispensing Limits (QL/DL), ACA preventive (AC), Behavioral Health (BH), and Non‑Member specific (NM) restrictions may apply as noted on the Drug List and in the Special Requirements column; presence of these tags indicates the corresponding program may affect coverage or require submission of clinical documentation.

All of the following general conditions apply:

- PA: If a drug is noted with 'PA' the provider must submit a prior authorization request and receive approval before coverage is provided.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List (Formulary) - Blue Cross and Blue Shield of New Mexico

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit prior authorization requests for medications flagged 'PA' and follow the payer's exception and specialty pharmacy procedures as noted.

SourceLink

On This Page

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Product-specific Requirements/Limits

Product-specific requirements, limits, and flags are documented on the BCBSNM 2026 Drug List. The following summarizes the types of per-product controls and flags that may appear and what they mean for coverage and prior authorization.

ALL of the following

Drugs must be listed on the BCBSNM 2026 Drug List to be considered for coverage.
Listing on the Drug List is a prerequisite for pharmacy benefit coverage.
Common product-level controls (one or more may apply):
- Prior Authorization (PA) — clinical documentation required and approval must be obtained before coverage.
- Step Therapy (ST) — member may be required to trial specified alternative(s) prior to coverage; exceptions can be requested.
- Quantity Limit / Dispensing Limit (QL/DL) — limits on quantity per fill or time period; member may pay full cost for quantities beyond limit.
- Formulary Tier Placement — drug coverage and member cost-share are determined by tier (e.g., Preferred Generic, Non‑Preferred Generic, Preferred Brand, Non‑Preferred Brand, Preferred Specialty, Non‑Preferred Specialty).
- Specialty designation (SP) — specialty drugs may have separate network, distribution, and management rules and may appear on a Specialty Drug List.
- ACA Preventive (AC) — subject to ACA preventive coverage requirements when applicable by plan.
- Behavioral Health (BH) — may have program-specific management rules.
- Non‑member/Plan Specific Flags (NM) — indicates coverage varies by specific plan design or member eligibility.
Members and providers should consult the Drug List entry for the specific product for the exact flags, prior authorization criteria, quantity limits, and any clinical criteria required for approval.
The Drug List on MyPrime.com or bcbsnm.com contains the authoritative per-product details.

Per-product requirements/limits

Per-product requirements and limits are applied at the individual drug level as listed on the Drug List. Examples of per-product criteria include required diagnoses, previous therapy trials, lab values, age restrictions, dosing limits, and approval durations.

ALL of the following

Approval is contingent on meeting the specific clinical criteria documented for the product on the Drug List (for example: diagnosis, prior therapies tried and failed, required monitoring or lab results).
Duration and renewal criteria: initial authorizations may be time-limited; renewals typically require documentation of continued benefit or adherence to clinical monitoring parameters.
Age and indication limits: some products are covered only for specified age ranges or FDA‑approved/recognized indications; off‑label use may not be covered unless supported by recognized clinical guidelines and plan policy.
Dosing and formulation limits: coverage may be restricted to specified formulations, strengths, or maximum daily/30‑day quantities; higher doses or non‑preferred formulations may be denied or require additional justification.

Formulary Product Requirement Flags

Formulary product requirement flags shown on the Drug List identify management programs or coverage attributes that affect how a product is processed by the plan.

ALL of the following

PA — Prior Authorization required for coverage as indicated on the Drug List.
ST — Step Therapy required; specified first‑line alternatives must be tried and documented unless an exception is approved.
QL/DL — Quantity or Dispensing Limits apply; check product entry for specific limits.
AC — ACA preventive drug; coverage determined per plan and applicable regulations.
SP — Specialty drug designation; may be managed through specialty pharmacy and carry specialty tier cost‑sharing.
p/np/P/NP — Tier identifiers (Preferred Generic 'p', Non‑Preferred Generic 'np', Preferred Brand 'P', Non‑Preferred Brand 'NP') determine member cost share and may reflect coverage preferences.

Applicable Products, Quantity Limits and Program Codes

Listed NDC/Drug entries (examples from part)NDCCovered

amoxicillin - multiple forms/dosages	Amoxicillin oral suspensions, capsules, tablets (various strengths)
amoxicillin & clavulanate - multiple forms/dosages	Amoxicillin-clavulanate (Augmentin) suspensions, chewables, tabs (various strengths)
azithromycin susp 100 mg/5ml	Zithromax oral suspension 100 mg/5 ml
azithromycin susp 200 mg/5ml	Zithromax oral suspension 200 mg/5 ml
azithromycin tab 250 mg	Zithromax 250 mg tablet (Z‑pak)
azithromycin tab 500 mg	Zithromax 500 mg tablet
clarithromycin - multiple forms	Clarithromycin tabs and suspensions (various strengths)
fidaxomicin (DIFICID) susp 40 mg/ml / tab 200 mg	DIFICID oral suspension 40 mg/mL and tablets 200 mg
doxycycline - multiple forms	Doxycycline hyclate and monohydrate tabs, caps, suspensions
ciprofloxacin susp/tab	Ciprofloxacin oral suspension and tablets

1–10 of 44

1/5

Products with Prior Authorization (PA)mixed

ARIKAYCE	Prior authorization typically required for ARIKAYCE (amikacin liposome inhalation)
APRETUDE	APRETUDE (cabotegravir) often requires PA
many specialty agents (IMCIVREE, GALAFOLD, PALYNZIQ, etc.)	Specialty, high‑cost therapies commonly require prior authorization
select oncology agents (XPOVIO, XALKORI, XOSPATA)	Oncology targeted therapies often require PA and documentation of indication
select hepatitis/HIV agents (BIKTARVY, BARACLUDE)	PA may apply depending on plan and indication

Products with Quantity Limits (QL) specifiedmixed

Insulin (multiple products)	Quantity limits apply to many insulin products (example thresholds listed below)
ARIKAYCE	Quantity limit example: ARIKAYCE 28 vials/28 days
Benlysta	Example QL: Benlysta 4 syringes/28 days
Common oncology oral QLs	Selected oral oncology agents may have monthly QLs
Glucagon rescue products	BAQSIMI, GVOKE, GLUCAGON kits - QLs per pack (one or two pack limits)

Products with Access Constraint (AC)mixed

Contraceptives (NUVARING, ANNOVERA, IUDs, implants)	Some contraceptives subject to specific benefit rules or age limitations
Controlled substance testosterone products	State dispensing limits and coverage constraints may apply
Certain infusible/clinic‑administered drugs	May be covered under medical benefit rather than pharmacy benefit

Drugs listed with Drug Tier P / NP groupsmixed

Preferred (P) and Non‑Preferred (NP) specialty/brand listings	Many brand and specialty drugs are categorized by plan into Preferred or Non‑Preferred tiers (see formulary index for tier-specific markings)
Preferred Generics (p) and Non‑Preferred Generics (np)	Generics are marked p or np per formulary; some brands remain in generic tiers when designated

OpenPayer

2026 Drug List (Formulary) - Blue Cross and Blue Shield of New Mexico

Coverage Summary

Exception Process & Provider Actions

Product-specific Requirements & Flags

Applicable Products, Quantity Limits and Program Codes

Provider Checklist — What to do before prescribing or billing