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CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2026 Drug List (Pharmacy Benefit Drug List) — Formulary and Coverage Criteria

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This document is Blue Cross and Blue Shield of New Mexico's 2026 pharmacy drug list describing covered outpatient prescription drugs, tier placement, special requirements (PA, ST, QL, AC), specialty pharmacy processes, and member/provider instructions. It affects BCBSNM members and their prescribing providers and pharmacies.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List (Pharmacy Benefit Drug List) — Formulary and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit required prior authorization and supporting documentation for drugs marked 'PA' and adhere to listed quantity limits and specialty pharmacy routing where indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~120+distinct drug lines (excerpt)

Accredospecialty partner

PA/QL/SPcommon utilization controls

6member tiers described

30/90typical supply lengths

Formulary Coverage & Conditions

General Pharmacy Coverage

Covered when consistent with benefit plan terms and any special requirements noted:

General coverage conditions: Drug must be listed on the BCBSNM Drug List and be FDA‑approved for the indicated use; coverage is subject to the member's benefit plan terms, formulary tier placement, and any Special Requirements listed (e.g., PA, ST, QL, AC).

Drugs not shown on the Drug List are not covered; some medications administered by a health care professional may be billed under the medical benefit.

Formulary tiering and utilization controls

Coverage and utilization management apply as indicated per listed product entries

Formulary tier and controls: Each listed drug is assigned a formulary tier (e.g., Preferred/Non‑Preferred) and may have Requirements/Limits such as Prior Authorization (PA), Quantity Limits (QL), Access Controls (AC), Specialty Pharmacy routing (SP), or Step Therapy (ST).as listed per product

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

Policy2026 Drug List (Pharmacy Benefit Drug List) — Formulary and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit required prior authorization and supporting documentation for drugs marked 'PA' and adhere to listed quantity limits and specialty pharmacy routing where indicated.

SourceLink

On This Page

Specific clinical criteria for PA or ST are not provided in these chunks; see product line entries for per‑drug flags.

Per-product formulary coverage markers

Coverage and requirements are specified per drug line as follows

Formulary entries: Each drug line in the Drug List shows the Drug Tier and any Requirements/Limits (e.g., QL, PA, SP, AC). Coverage and dispensing are governed by the flags shown for that product.per product entry

No unified clinical medical‑necessity criteria are present in this excerpt; decisions follow per‑product Requirements/Limits.

Coverage conditioned on listed administrative controls

Coverage entries indicate that drugs are subject to utilization management when ALL of the following listed controls are present for a product

Standard formulary controls: To be covered when controls are present, the product must: be on the Drug List at the listed Drug Tier; have any required Prior Authorization (PA) approved before dispensing; not exceed stated Quantity Limits (QL); and be dispensed via Specialty Pharmacy (SP) when designated.as listed per product

Specific clinical indication criteria for PA or ST are not included in these chunks; follow product line Requirements/Limits and provider documentation rules.

Formulary coverage controls (excerpt)

Coverage and utilization management indications for listed drugs (examples from excerpt):

Prior authorization (PA): Selected products require prior authorization before coverage is available (examples in the excerpt include certain prednisolone formulations, testosterone products, MYFEMBREE).

PA is shown in the Requirements/Limits column for affected products.

Quantity limits (QL): Many products include quantity limits (examples: prednisolone sod phosphate oral solution QL 900 mls/30 days; various testosterone formulations with per‑period limits; MYFEMBREE QL 30 tablets/30 days).see product QL values

Dispensing beyond QL typically requires PA or will be limited at claim adjudication.

Access control / Step edits (AC / ST): Some contraceptives and other products are labeled AC (access control) and/or ST (step therapy), indicating access or step requirements before coverage. Examples include contraceptive entries marked AC and products marked ST where noted (e.g., Kerendia).

Where AC or ST is listed, follow the plan's step/ access procedures and exception processes.

Formulary listing with conditional coverage

Coverage entries list drug, strength/form, formulary tier, and any requirements/limits. Coverage is conditional where PA, QL, SP, or ST are indicated.

Conditional formulary coverage: When a drug entry includes PA, QL, SP, or ST, coverage is provided only when those Requirements/Limits are met (e.g., obtain PA if listed; adhere to the stated QL; use SP channel if designated).per Requirements/Limits in drug line

Examples in these chunks include ACTHAR (PA, SP), CRENESSITY (PA, QL, SP), and GENOTROPIN (PA, SP).

Coverage with utilization management

Coverage of listed drugs is subject to the following plan-level requirements as shown per drug:

PA and QL enforcement: Drugs labeled with Requirements/Limits.PA require an approved prior authorization prior to coverage; drugs with Requirements/Limits.QL are subject to the specified quantity limit per time period and claims exceeding those limits require PA or are processed at member expense.as specified per product entry

Detailed clinical PA criteria are not provided in this excerpt; follow the payer's PA form/process and document clinical rationale.

Formulary product-level coverage

Coverage and utilization controls as listed per product line

Per‑product coverage entry: Each product line entry specifies Drug Tier and, where applicable, Requirements/Limits (PA, QL, SP, AC). Providers must follow those controls for coverage and dispensing; specific clinical criteria for authorization are found in the applicable PA process or clinical policy, not in these listing excerpts.

Examples: inhaled respiratory products and biologics shown with QL and PA/SP designations in these chunks.

Coverage conditional on adherence to listed Requirements/Limits

Coverage is provided according to formulary tier with utilization controls where indicated; specific PA/QL/SP must be met for listed drugs.

Formulary compliance for coverage: Drug is covered when dispensed consistent with the listed Drug Tier and any Requirements/Limits (e.g., obtain PA where indicated; comply with QL; route via SP when required).per product Requirements/Limits

Examples include BYLVAY (PA, SP) and CIMZIA (PA, QL, SP).

Drugs must appear on the BCBSNM Drug List to be covered. Drugs not shown on the drug list are not covered. The plan may also exclude coverage for non‑FDA‑approved products, repackaged medications, and some compounded medications; members and providers should verify coverage and any payment obligations in the member's benefit materials or by calling the number on the ID card.

Within the provided excerpts there are no explicit categorical exclusions called out. Coverage decisions in this segment are expressed at the product level by formulary tier and Requirements/Limits flags (e.g., PA, QL, SP) rather than by listing broad exclusions for drug classes or clinical scenarios.

The excerpt does not state clinical conditions that would automatically exclude coverage. Instead, entries identify per‑product controls and designations (for example, PA for prior authorization, QL for quantity limits, and SP for specialty pharmacy). Coverage is therefore governed by those product‑level flags rather than by exclusionary clinical diagnoses in this segment.

This portion of the drug list has no explicit clinical exclusions. Items are presented with their formulary tiering and any stated Requirements/Limits (for example, PA, QL, SP). Providers should follow those per‑product requirements when seeking coverage rather than relying on exclusion language in this excerpt.

No explicit exclusions are listed in these chunks; the content consists primarily of drug product lines with assigned formulary tiers and Requirements/Limits. Coverage determinations referenced here depend on adherence to the product‑level controls shown (e.g., PA, QL), not on named exclusion criteria.

These entries do not include explicit exclusions. The segment assigns drug tiers and, where applicable, utilization controls such as PA and QL, which are the operative coverage conditions in this excerpt.

No exclusion criteria are specified in this excerpt. Coverage stance is shown at the product level: many entries are covered but subject to formulary tier placement and utilization controls (for example, some products are listed with PA and/or QL requirements).

Within these chunks there are no explicit exclusions. The listings identify drug tier and any Requirements/Limits (e.g., PA, QL, SP) that must be met for coverage. Providers should follow those product‑level rules when submitting claims or requests for authorization.

No explicit exclusions are listed in these chunks.

These excerpts do not present explicit exclusions. Formulary entries are shown with tiers and Requirements/Limits; coverage is determined by those product‑level controls rather than by named exclusions in this segment.

In the provided document segments no product is labeled as Not Medically Necessary. Instead, coverage status is expressed through formulary tiering and utilization management markers (for example, PA, QL, and SP) attached to individual drug listings.

Formulary Code & Example Listings

Penicillins and combinationsmixed

AMOXICILLIN	amoxicillin formulations listed with tiers and strengths (chew tabs, caps, susp, tabs)
AMOXICILLIN/CLAVULANATE	amoxicillin & k clavulanate formulations (suspensions, tabs, ER)

Cephalosporinsmixed

CEPHALOSPORINS

cef- class agents (cefadroxil, cefaclor, cefdinir, cefixime, cefpodoxime, cefprozil, cefuroxime, cephalexin) with tiers

Macrolides and relatedmixed

MACROLIDES

azithromycin, clarithromycin, erythromycin, fidaxomicin entries with QLs

Tetracyclines & Fluoroquinolonesmixed

TETRACYCLINES	doxycycline, minocycline, sarecycline, omadacycline entries
FLUOROQUINOLONES	ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin listings

Aminoglycosides & Antimycobacterialmixed

AMINOGLYCOSIDES	amikacin liposome (ARIKAYCE), tobramycin inhalation products, paromomycin
ANTIMYCOBACTERIAL AGENTS	isoniazid, ethambutol, pyrazinamide, rifampin, bedaquiline, pretomanid, rifapentine

Antifungals & Antiviralsmixed

ANTIFUNGALS	itraconazole, posaconazole, voriconazole, fluconazole, isavuconazonium, oteseconazole
ANTIVIRALS	HIV and antiviral agents (abacavir, acyclovir, cabotegravir/APRETUDE, multiple ARVs)

Formulary requirement codes and examplesmixed

QL (30 tablets/30 days)	Common quantity limit for many oral tablet regimens (example listed)
QL (60 capsules/30 days)	Quantity limit example for atazanavir formulations
QL (120 capsules/30 days)	Example QL for itraconazole capsule
AC	Access / administrative control appears alongside some products
PA	Prior Authorization flag present for several specialty agents
SP	Special Program / Specialty Pharmacy flag present for certain products

Antimicrobials and related formulationsmixed

vancomycin hcl cap 125 mg	vancomycin hcl cap 125 mg (Vancocin)
vancomycin hcl cap 250 mg	vancomycin hcl cap 250 mg (Vancocin)
linezolid tab 600 mg	linezolid tab 600 mg (Zyvox)
linezolid for susp 100 mg/5ml	linezolid for susp 100 mg/5ml (Zyvox)
rifaximin tab 200 mg	XIFAXAN - rifaximin tab 200 mg
rifaximin tab 550 mg	XIFAXAN - rifaximin tab 550 mg

Vaccinesmixed

ABRYSVO	rsv pre-fusion f a&b vac recomb for im soln
AREXVY	rsv pre-fusion vaccine recomb adjuvanted for im susp
COMIRNATY	covid-19 mrna vac tris-pfizer im susp
SPIKEVAX	covid-19 mrna vaccine-moderna
GARDASIL 9	human papillomavirus (hpv) 9-valent recomb vaccine
SHINGRIX	zoster vaccine recombinant adjuvanted for im inj 50 mcg/0.5ml

Allergen immunotherapy, peanut OIT, antineoplasticsmixed

PALFORZIA	peanut powder-dnfp starter/maintenance/titration and level packs (multiple levels)
abiraterone acetate 250 mg	abiraterone acetate tab 250 mg (Zytiga)
abiraterone acetate 500 mg	abiraterone acetate tab 500 mg (Zytiga)
alectinib cap 150 mg	ALECENSA - alectinib hcl cap 150 mg
brigatinib	ALUNBRIG - brigatinib (various strengths and initiation pack)

No CPT/HCPCS/ICD-10/NDC codes in this segmentmixed

No codes listed

Drug product list (no explicit billing codes)mixed

N/A	No CPT/HCPCS/ICD codes listed in this excerpt; entries are drug product lines with tiers and requirements.

Sample drug strengths listedmixed

100 unit/ml (70-30)	NOVOLOG MIX 70/30 (insulin aspart prot & aspart) pen-inj 100 unit/ml (70-30)
100 unit/ml	INSULIN GLARGINE-YFGN inj 100 unit/ml

Additional strengthsmixed

300 unit/ml	TOUJEO MAX SOLOSTAR insulin glargine pen-injector 300 unit/ml
80 unit/ml	ACTHAR corticotropin inj gel 80 unit/ml

Sample specialty drug entries from listNDC | mixed

pasireotide diaspartate inj 0.3 mg/ml, 0.6 mg/ml, 0.9 mg/ml	SIGNIFOR - pasireotide diaspartate injection strengths listed with Requirements/Limits.PA, QL (8 capsules/28 days)
lonapegsomatropin-tcgd cartridges	SKYTROFA - lonapegsomatropin-tcgd cartridges with Requirements/Limits.PA, QL (8 capsules/28 days)
sodium phenylbutyrate oral powder 3 gm/teaspoonful; tab 500 mg	Buphenyl - listed with Requirements/Limits.PA, QL (8 capsules/28 days)

Additional specialty entriesNDC | mixed

pegvisomant for injection 10 mg - 30 mg	SOMAVERT - pegvisomant injection with Requirements/Limits.PA, QL (30 vials/30 days)
asfotase alfa subcutaneous inj 18 mg/0.45 ml, 28 mg/0.7 ml, 40 mg/ml, 80 mg/0.8 ml	STRENSIQ - Requirements/Limits.PA, QL (8 capsules/28 days)
teriparatide soln pen-inj 560 mcg/2.24 ml	Forteo - Requirements/Limits.PA, QL (2.24 mls/28 days)

Cardiovascular agents (selected)NDC | mixed

DIGOXIN	digoxin oral soln 0.05 mg/ml; digoxin tabs 62.5 mcg, 125 mcg, 250 mcg
ASPRUZYO SPRINKLE	ranolazine er granules packet 1000 mg
ISOSORBIDE AGENTS	isosorbide dinitrate and isosorbide mononitrate formulations listed

Formulary drug listings with tiers and utilization controlsmixed

simvastatin tab 10 mg, 20 mg, 40 mg	Zocor listed with drug tier p
VASCEPA - icosapent ethyl cap 0.5 gm, 1 gm	Drug Tier = np
ADEMPAS - riociguat tab	Requirements/Limits = PA, QL (90 tablets/30 days), SP
ENTRESTO - sacubitril-valsartan sprinkle cap	Requirements/Limits = PA, QL (240 capsules/30 days)
REPATHA - evolocumab	Requirements/Limits = PA, QL (6 syringes/28 days)
FASENRA PEN - benralizumab	Requirements/Limits = PA, QL (1 pen/28 days), SP

Formulary drug list (selected entries in these chunks)mixed

fluticasone-salmeterol (Advair Diskus)	fluticasone-salmeterol aer powder (Advair Diskus) strengths with QL (60 blisters/30 days)
INCRUSE ELLIPTA	umeclidinium inhalation powder QL (30 blisters/30 days)
NUCALA - mepolizumab	mepolizumab formulations with PA, QL and SP designations
TRELEGY ELLIPTA	fluticasone-umeclidinium-vilanterol with QL (1 inhaler/30 days)
VENTOLIN HFA	albuterol inhaler QL (2 inhalers/30 days)
CREON / ZENPEP	pancrelipase products listed
SUCRAID - sacrosidase soln	Requirements/Limits = PA, QL (300 mls/30 days)

Formulary drug entries (sample)mixed

ondansetron hcl tab 4 mg, 8 mg	ondansetron hcl tab 4 mg, 8 mg (Drug Tier = p)
ONDANSETRON ODT 16 mg	ondansetron orally disintegrating tab 16 mg (Drug Tier = NP)
SANCUSO TD PATCH	granisetron td patch 3.1 mg/24hr (Drug Tier = NP)
VARUBI therapy pack	rolapitant hcl tab therapy pack 2 x 90 mg (Drug Tier = P)

Selected biologic and GI agents with limitsmixed

TREMFYA prefilled syringe 200 mg/2ml	guselkumab soln prefilled syringe 200 mg/2ml (PA, QL 1 syringe/28 days, SP)
TRULANCE 3 mg	plecanatide tab 3 mg (QL 30 tablets/30 days)

Formulary drug product entries (sample)mixed

ALPRAZOLAM INTENSOL	alprazolam conc 1 mg/ml
alprazolam ODT	alprazolam orally disintegrating tab 0.25/0.5/1/2 mg
BUCAPSOL - buspirone	buspirone hcl cap 7.5 mg; 10 mg
buspirone cap 15 mg	buspirone hcl cap 15 mg (sample strengths)

Antipsychotics and related productsmixed

aripiprazole oral solution 1 mg/ml	aripiprazole oral solution 1 mg/ml (QL 900 mls/30 days)
aripiprazole ODT 10 mg, 15 mg	aripiprazole orally disintegrating tab 10 mg, 15 mg (QL 60 tablets/30 days)
CLOZAPINE ODT 12.5 mg	clozapine orally disintegrating tab 12.5 mg (Drug Tier = NP)
NUPLAZID 34 mg	NUPLAZID - pimavanserin tartrate cap 34 mg (Requirements/Limits = PA, QL 30 capsules/30 days)

Quantity limits (examples)

Typical formatsExamples include tablet counts per days (e.g., 60 tablets/180 days; 28 tablets/180 days)

Vials and kitsExamples include 28 vials/28 days; 1 kit/56 days

Liquid volumesExamples include 280 mLs/56 days; 224 mLs/56 days

Common monthly tablet QL30 tablets/30 days (common for many oral tablet regimens)

Quantity Limit examples

Short-course antiviral packsEPCLUSA: QL 28 tablets/28 days (also 28 packs/28 days for pellet pack)

Monthly tablet limitsVOSEVI: QL 30 tablets/30 days

Extended supply examplesSOVALDI: QL 30 tablets/30 days; TRIUMEQ: QL 30 tablets/30 days

Therapy-pack limitsXOFUZA: QL 2 tablets/120 days (example therapy pack limit)

Example QL entries

Kits and large-volume liquidsQL (1 kit/56 days); QL (600 mLs/180 days)

Capsules examplesQL (120 capsules/30 days) as used for some oral oncology/antibiotic formulations

Inhalation/nebulizer quantitiesTOBRAMYCIN nebu soln QL 280 mLs/56 days or 224 mLs/56 days depending on product

Authorization, Documentation & Denial Risks

Prior Authorization

Prior authorization (PA) required for drugs flagged 'PA'

Certain medications listed on the BCBSNM Drug List require prior authorization (PA) before coverage will be provided; when commonly required this is indicated with 'PA' in the Special Requirements column. Providers must obtain and clear an approved PA prior to dispensing drugs marked PA.

If a prior authorization is commonly required it will be noted adjacent to the medication with 'PA' in the Special Requirements column.
PA must be approved before coverage is available for the medication.

Prior Authorization

Obtain PA for select specialty and high-cost agents (examples listed)

Prior authorization is required for many specialty or high-cost agents (examples shown in the drug list include ARIKAYCE, tobramycin inhalation products, isavuconazonium/posaconazole, oteseconazole, and other specialty antifungals/antibiotics). Verify PA before prescribing or dispensing these agents.

Examples: ARIKAYCE and inhaled tobramycin formulations have PA/QL/SP designations (see inhaled aminoglycoside entries).
Certain systemic antifungals (e.g., isavuconazonium, posaconazole) are listed with PA.

Prior Authorization

PA required for listed hepatitis C and other specialty antivirals

Selected specialty antivirals for hepatitis C (EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) are marked with PA and, in many cases, SP; providers must submit prior authorization requests for these regimens and follow specialty program routing when indicated.

EPCLUSA, HARVONI, MAVYRET, SOVALDI and VOSEVI are shown with Requirements/Limits = PA and SP and have QL values (e.g., 28–30 per month).
VOSEVI and other sofosbuvir-containing regimens list both PA and SP and require prior authorization and specialty fulfillment.

Prior Authorization

PA required for many antineoplastics and oncology agents

Many antineoplastic and oncology oral specialty agents require prior authorization; obtain PA per product entry before dispensing (examples include abiraterone, alectinib, brigatinib and numerous oral oncology therapy packs).

Antineoplastics such as abiraterone acetate, alectinib, brigatinib and multiple therapy packs are listed with Requirements/Limits = PA (often with QL and SP).
PA is required prior to coverage for these oncology agents and starter/therapy packs per the drug list entries.

Prior Authorization

Check each product line for PA (per-product PA flags apply)

Many individual formulary products across sections are designated 'PA' (and may also carry QL and/or SP flags); providers must review each product line for its specific PA requirement and secure authorization prior to coverage.

Per-product entries indicate Drug Tier and Requirements/Limits (PA, QL, SP) which govern coverage.
Coverage is conditional on meeting the listed Requirements/Limits for each drug line.

Prior Authorization

PA plus specialty pharmacy (SP) routing required where 'SP' indicated

Several specialty drugs are designated SP or require specialty pharmacy routing in addition to PA; providers should submit PA requests and ensure dispensing through the specialty pharmacy when the product lists 'SP'.

Examples: many oncology and biologic agents carry SP designation; specialty products (e.g., PALFORZIA, various biologics) list SP in Requirements/Limits.
Claims for products with both PA and SP flags may be denied or delayed if not routed through specialty pharmacy.

Prior Authorization

PA required for certain formulations (prednisolone soln, testosterone, etc.)

Certain specific products (e.g., prednisolone sodium phosphate oral solution and multiple testosterone formulations) are listed with PA and quantity limits; providers must obtain PA and observe the stated QL when requesting these products.

Prednisolone sodium phosphate oral solution 10 mg/5 ml is listed with Requirements/Limits = PA, QL (900 mls/30 days).
Multiple testosterone topical and transdermal formulations show Requirements/Limits = PA, QL (examples: 30 packets/30 days; 2 bottles/30 days; 60 packets/30 days).

Prior Authorization

PA required for selected antidiabetic agents (examples shown)

Selected antidiabetic agents are marked with PA and, where specified, QL (examples include metformin oral solution Riomet, MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY); secure PA and adhere to product-specific quantity limits before dispensing.

Metformin oral solution (Riomet) — Requirements/Limits = PA, QL (780 mls/30 days).
MOUNJARO and OZEMPIC products are shown with PA and specific QL values (e.g., MOUNJARO QL 4 pens/28 or 180 days; OZEMPIC QL 1 pen/28 days).

Prior Authorization

PA required for select endocrine and specialty drugs (examples)

Certain endocrine and other specialty agents (e.g., ACTHAR, CRENESSITY, GENOTROPIN, OMNITROPE) require prior authorization and in some cases specialty pharmacy handling; obtain PA and follow SP routing where listed.

ACTHAR — Requirements/Limits = PA, SP.
GENOTROPIN — Requirements/Limits = PA, SP; CRENESSITY listed with PA and QL.

Prior Authorization

PA required for numerous specialty drugs (observe QL where noted)

Multiple specialty and high-cost drugs throughout the list carry 'PA' flags and may also include QL; providers must obtain prior authorization and adhere to any listed quantity limits to avoid coverage denial.

Examples in specialty sections show Requirements/Limits = PA and QL (e.g., SIGNIFOR, SKYTROFA, SOMAVERT, TRYNGOLZA).
Claims may be denied if PA and QL are not met for drugs designated PA.

Prior Authorization

Obtain PA and confirm QL for specialty formulations with PA/QL/SP flags

Certain specialty formulations require both PA and QL (and sometimes SP) — review the product entry for required authorization and quantity limits before prescribing or dispensing (examples shown across multiple sections).

Product lines frequently display combinations such as 'PA, QL, SP' (see cardiac, pulmonary hypertension and other specialty drug entries).
Obtain PA and confirm quantity limit adherence for these products to secure coverage.

Prior Authorization

PA required for many specialty/PA drugs (cardio, rare disease, biologics)

Many specialty and biologic agents across the formulary are marked 'PA' — providers must submit prior authorization requests for these products and confirm any associated QL or SP routing shown in the product entry.

Examples include ADEMPAS, CAMZYOS, ENTRESTO, VYNDAMAX/VYNDAQEL and others listed with PA, QL and SP.
PA must be obtained prior to dispensing for coverage of these specialty agents.

Prior Authorization

Confirm PA for selected high-cost/specialty products listed

Certain high-cost or specialty products are explicitly listed with PA in their Requirements/Limits (see specific product entries); providers must obtain prior authorization for coverage and follow any SP or QL instructions.

Check each product line for its PA designation and any linked SP or QL controls before prescribing.
Absence of approved PA may result in denial or non-payment for drugs listed with PA.

Prior Authorization

PA and SP required for many specialty and selected GI agents

Numerous specialty and select GI agents (e.g., BYLVAY, CHOLBAM, CIMZIA, GATTEX) are listed with PA and often SP; providers must submit prior authorization and ensure specialty pharmacy routing where required.

BYLVAY — Requirements/Limits = PA, SP.
CHOLBAM — Requirements/Limits = SP (specialty handling).
CIMZIA and GATTEX list PA and SP with starter-kit QL in some instances.

Prior Authorization

PA required for listed specific agents (e.g., NUPLAZID)

Certain products (example: NUPLAZID — pimavanserin tartrate) are listed with PA; obtain prior authorization according to the product entry prior to dispensing to avoid coverage denial.

NUPLAZID — Requirements/Limits = PA, QL (30 capsules/30 days).
Check the product entry for PA and QL before prescribing.

Step Therapy

Step therapy (ST) — try preferred first-line drug or request exception

Step therapy (ST) may require patients to try a first-line, preferred medication before coverage for the requested drug is available; when applicable the list notes 'ST' in the Special Requirements column and providers may submit step therapy exception requests.

If the preferred first-line drug is not appropriate, the prescriber can submit a step therapy exception request (call the number on the member ID card).
Products that commonly require step therapy will be noted with 'ST' adjacent to the medication.

Note

Observe 'SP' specialty pharmacy designation and route accordingly

Products marked 'SP' indicate specialty handling or specialty pharmacy fulfillment; providers must observe SP routing requirements when the drug entry includes the 'SP' designation.

Examples: PALFORZIA, many oncology and biologic agents are marked SP and require specialty fulfillment.
Failure to route through specialty pharmacy when required may result in denial or delayed coverage.

Note

Observe 'AC' access-control flags on contraceptives and follow PA/AC rules

Certain contraceptives and related products are marked 'AC' (access control) and may include PA or step elements; review product entries and submit any required PA or follow AC rules when billing or dispensing.

Contraceptives show Requirements/Limits = AC and sometimes PA and QL (e.g., ring QL 1 ring/365 days).
AC likely indicates plan-specific access controls that may require authorization or program rules.

Step Therapy

Step therapy example — Kerendia marked ST with QL

Kerendia (finerenone) is an example of a product marked with ST (step therapy) in addition to a quantity limit (QL 30 tablets/30 days); when ST is present providers must follow step requirements or submit an exception.

KERENDIA — Requirements/Limits = QL (30 tablets/30 days), ST.
If step therapy applies, try the preferred therapy first or submit an exception request per the exception process.

Documentation Required

PA and QL submissions require supporting documentation (per PA flags)

Products shown with 'PA' or 'QL' (and/or 'SP') in the drug list require supporting documentation as part of the prior authorization or quantity-limit exception process; the drug list notes that entries marked 'PA' imply documentation is required, though specific forms/criteria are not listed in this excerpt.

Providers must supply clinical information and justification when submitting PA requests (e.g., diagnosis, prior therapies) as implied by the PA/QL designations.
If requesting quantity above the QL, supportive justification must be provided; specific documentation requirements are available from the plan.

Note

Exception request process and review timeframes

Providers or members may request a Drug List exception or a step therapy exception by calling the number on the member's ID card; BCBSNM will notify the prescriber of the decision within three business days (standard) or within 24 hours for expedited requests when the condition jeopardizes life/health/function.

Standard decision timeframe: within three business days of receiving the request.
Expedited review (when life/health/function jeopardized): decision within 24 calendar hours.

Denial Risk

Coverage exclusions — non‑listed, non‑FDA or repackaged drugs not covered

Drugs that are not shown on the BCBSNM Drug List, non–FDA‑approved drugs, or repackaged medications are not covered; prescribing or billing for such agents may result in denial.

Non–FDA‑approved drugs and repackaged medications are explicitly not covered by the plan.
Verify that the drug appears on the Drug List before submitting claims to avoid denial.

Denial Risk

Prior authorization required for select inhaled antibiotics (risk of denial)

Certain inhaled aminoglycosides and tobramycin formulations require PA/QL/SP (e.g., TOBI PODHALER, tobramycin nebulizer solutions); lack of required PA or failure to meet QL/SP routing may trigger claim denial.

TOBI PODHALER and tobramycin nebu solutions list Requirements/Limits including PA, QL (e.g., 280 mls/56 days), and SP.
Obtain PA and adhere to QL/SP routing for inhaled aminoglycosides to avoid denial.

Denial Risk

PA required for select antifungals — absence of PA may cause denial

Certain systemic antifungals (e.g., isavuconazonium (CRESEMBA), posaconazole, itraconazole) are listed with PA; claims submitted without the required PA may be denied.

CRESEMBA — Requirements/Limits = PA.
Other antifungals in the antifungal section are marked PA and may require authorization prior to coverage.

Prior Authorization

PA (and often SP) required for selected hepatitis C agents

Hepatitis C direct‑acting antiviral regimens (EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI) are listed with 'PA' and often 'SP'; providers must secure PA (and follow SP routing) for these agents before dispensing to ensure coverage.

EPCLUSA, HARVONI, MAVYRET, SOVALDI and VOSEVI each show Requirements/Limits = PA, QL and SP in the drug list.
VOSEVI and other sofosbuvir‑containing regimens specifically list both PA and SP — prior authorization and specialty program routing apply.

Prior Authorization

PA and specialty program required for certain sofosbuvir‑containing regimens

Direct-acting antiviral regimens containing sofosbuvir (e.g., VOSEVI) are shown with PA and SP designations; providers must submit PA and route through the specialty program as designated to secure coverage.

VOSEVI — Requirements/Limits = PA, QL (30 tablets/30 days), SP.
PA and SP designations indicate both authorization and specialty fulfillment requirements.

Denial Risk

Denial risk when PA/QL/SP requirements are not met

Requests for drugs listed with 'PA' and/or exceeding a stated QL or not routed via 'SP' are at risk for denial if authorization or specialty routing and quantity‑limit compliance are not met.

Denial risk exists when PA is missing, a requested quantity exceeds QL, or specialty pharmacy routing (SP) is not used where required.
Verify PA approval and QL compliance and confirm SP routing to prevent claim denials or delays.

Denial Risk

Claims may be denied without required PA

Claims for drugs listed with 'PA' may be denied if the required prior authorization is not obtained prior to dispensing; providers should confirm PA approval before billing.

The drug list specifies PA for many products; absence of an approved PA can result in denial or non‑payment.
Check plan records or call the number on the member ID card to verify authorization status.

Denial Risk

QL exceedance or missing PA may trigger denial — submit justification

Requests exceeding stated quantity limits (example: prednisolone sodium phosphate oral solution QL 900 mL/30 days) or without required PA may be denied; submit justification with PA requests for quantities above QL.

Prednisolone sod phosphate oral solution 10 mg/5 mL — Requirements/Limits = PA, QL (900 mLs/30 days).
If requesting quantities above the QL, include justification in the PA submission to support medical necessity.

Prior Authorization

PA and quantity limits apply to select products — obtain PA or observe QL

Products listed with PA or QL (e.g., metformin solutions, various specialty agents) require prior approval or will be limited to the indicated quantity; providers must obtain PA or dispense within the QL to ensure coverage.

Metformin oral solution (Riomet) — Requirements/Limits = PA, QL (780 mLs/30 days).
Many specialty products list PA and a QL; adherence to these listed controls governs coverage.

Prior Authorization

PA conditioned coverage for selected endocrine/specialty agents

Coverage for listed specialty or high-cost drugs (examples: ACTHAR, CRENESSITY, GENOTROPIN, OMNITROPE) may be conditioned on prior authorization; providers should secure PA prior to dispensing.

ACTHAR — Requirements/Limits = PA, SP.
GENOTROPIN and OMNITROPE are listed with PA and often SP; obtain authorization per product entry.

Denial Risk

Failure to meet PA or QL may result in claim denial

If PA and specified QL are not met for drugs designated with Requirements/Limits.PA or QL, claims may be denied; providers must confirm authorization and that the dispensed quantity does not exceed listed QL.

Claims for listed drugs may be denied if PA is missing or if the quantity dispensed exceeds the QL.
Confirm PA approval and QL compliance before claim submission.

Prior Authorization

PA + SP requirements — ensure both authorization and specialty fulfillment

Claims for products that have both 'PA' and 'SP' flags may be denied or delayed if an approved prior authorization is not in place or if specialty pharmacy fulfillment is not used; ensure both PA approval and appropriate SP routing.

Many product entries combine PA and SP (e.g., REPATHA, various biologics); absence of approved PA or SP routing can prevent coverage.
Coordinate PA submission and specialty pharmacy fulfillment to avoid denials or delays.

Denial Risk

Denial triggers: missing PA, exceeding QL, or not using SP

Claims lacking required Prior Authorization (PA), Quantity Limits (QL), or Specialty Pharmacy (SP) routing may be denied per the product's Requirements/Limits; verify all listed controls before dispensing and billing.

Denial triggers include missing PA, exceeding QL, or failure to route via SP where required.
Review each product's Requirements/Limits before prescribing to confirm necessary administrative steps.

Prior Authorization

PA and QL triggers — example NUPLAZID

Coverage may be subject to prior authorization and/or quantity limits for certain products (example shown: NUPLAZID — Requirements/Limits = PA, QL 30 capsules/30 days); obtain PA and adhere to QL to secure coverage.

NUPLAZID — Requirements/Limits = PA, QL (30 capsules/30 days).
Check the drug entry for PA and QL and obtain approval/adhere to limits before dispensing.

Checks When Initiating Therapy

Initial therapy — not specified

No item-specific initial therapy clinical criteria are present in the provided excerpt.

Initial therapy: Coverage flags (PA, QL, SP, ST) are shown per product; the excerpt does not provide drug‑specific medical necessity clinical entry criteria for initiation of therapy.

Refer to the full clinical policy or PA criteria for any drug‑specific initial therapy requirements.

Initial therapy authorization checks

When initiating therapy, check tiering and any QL/PA flags before dispensing

Initial dispensing check: Before the first fill, verify the drug's formulary tier, whether Prior Authorization (PA) is required and approved, the applicable Quantity Limit (QL), and whether Specialty Pharmacy (SP) routing is required. Obtain and document any required prior authorization or supporting clinical documentation prior to dispensing when PA is indicated.

Applies to agents listed with PA/QL/SP (examples in the Drug List include ACTHAR, GENOTROPIN, EPCLUSA, etc.).

Quantity limits for initial fills

Quantity‑limited initial fills: Initial fills must adhere to the product's stated quantity limit (QL). Examples from the listing include TRYNGOLZA (QL 1 injection device/28 days), TYMLOS (QL 1.56 mls/30 days), and VOXZOGO (QL 30 vials/30 days).per product QL

Dispensing beyond the QL generally requires prior authorization or will be processed at member expense.

Step Therapy Rules & Examples

Drug / Example	Step Therapy (ST) Note	Special Requirements
General: Try preferred first-line medication before coverage of program drug when step therapy applies
ST flagged items: AUVELITY, CLOZAPINE ODT, ESCITALOPRAM (example entries)
If ST applies, noted with 'ST' in the Special Requirements column; providers may submit a step therapy exception (call number on ID card).

Observation	Implication for Step Therapy	Supporting Example / Notes
Some products carry clinical access edits (AC) or quantity limits (QL)
AC or QL may functionally require trial of other agents or limit access prior to coverage, but explicit multi-step sequences are not provided
Contraceptives entries show AC and QL flags (e.g., many combined oral contraceptives listed with AC, QL)

Formulary Item	Tier	Primary Controls (PA / QL / SP / ST)
BIKTARVY (bictegravir-emtricitabine-tenofovir AF)
Drug Tier: P (example)
Requirements/Limits = QL (30 tablets/30 days)
metronidazole tab 250 mg, 500 mg
Drug Tier: p
Requirements/Limits = . (no explicit ST)
Advair Diskus (fluticasone-salmeterol)
Drug Tier: np
Requirements/Limits = QL (60 blisters/30 days)

Agent / Class	PA Present?	Notes
Selected antineoplastics (e.g., abiraterone acetate)
Yes — PA listed
Many oncology agents require PA and often have QL and SP designations (examples in oncology sections).
Brigatinib (ALUNBRIG)
Yes — PA listed
Requirements/Limits include PA, QL and SP for initiation packs and chronic supplies.

PALFORZIA Level / Pack	Tier	Requirements / Handling
PALFORZIA INITIAL DOSE ES (starter pack levels)
Drug Tier: NP
Requirements/Limits = SP (specialty program handling) for starter/maintenance/titration packs
PALFORZIA LEVEL 11 (maintenance/titration packets)
Drug Tier: NP
Requirements/Limits = SP (specialty handling indicated)

Observation	Step Therapy Sequence Provided?	Primary Controls Noted
Overall excerpt contains single-line formulary entries with flags
No — explicit ST sequences are not described in this segment
Coverage primarily governed by PA, QL, and SP as listed per product

Contraceptive / Product	Access Control (AC) / PA	Implication
Multiple combined oral contraceptives (examples: desogestrel-ethinyl estradiol products)
Marked with AC and often QL; some entries include PA
AC indicates plan-specific access control and may imply prior steps or documentation prior to coverage
ELLA (ulipristal acetate 30 mg)
Drug Tier = P; Requirements/Limits = AC, QL (2 tablets/365 days)
AC and QL indicate controlled access and quantity restriction prior to coverage

Drug	ST Flag	Other Controls
KERENDIA (finerenone) 10 mg, 20 mg
ST indicated
Requirements/Limits = QL (30 tablets/30 days) and ST noted alongside QL

Policy Statement	Action Required Before Coverage	Examples / Notes
Prior authorization required for specified drugs
Obtain PA prior to coverage / dispensing when 'PA' is listed in Requirements/Limits
Examples include many antineoplastics and select antivirals; PA noted adjacent to product lines in the drug list

Step	Action / Description	Notes
Step 1
Try preferred first-line medication (per benefit plan) before the program drug when ST applies
If preferred agent is not appropriate, provider may request a step therapy exception (see exception process).

Erectile Dysfunction Agent	Quantity Limit	Notes
Avanafil (Stendra) 50/100/200 mg
QL (8 tablets/30 days)
Example of QL applied to ED agents — limit typically 8 tablets/30 days for many PDE5 agents
Sildenafil (Viagra) 25/50/100 mg
QL (8 tablets/30 days)
Tadalafil formulations vary by strength; some strengths have QL 8 tablets/30 days or 30 tablets/30 days depending on indication

Observation	Step Therapy Sequence Present?	Policy Controls
Large sections list drugs with tier and utilization controls
No — explicit ST steps are not present in these chunks; entries show flags only
Coverage governed by PA/QL/SP markers per product line

Biologic / Starter Kit	PA / QL / SP	Implication
Certolizumab pegol prefilled syringe kit
Requirements/Limits = PA, QL (1 kit/180 days), SP
PA and kit-specific QL plus SP routing required prior to coverage and dispensing
Orkambi (lumacaftor-ivacaftor) tablets/granules
Requirements/Limits = PA, QL (120 tablets/30 days / 60 packets/30 days), SP
Example of biologic/specialty agents requiring PA and having starter/pack-specific QL

Product	ST Designation	Policy Note
AUVELITY (dextromethorphan–bupropion) tab ER
Marked ST in Requirements/Limits in listing
Designated 'ST' requires step therapy per formulary rules before coverage unless exception granted

Product	ST Flag	Notes / Controls
CLOZAPINE ODT 12.5 mg (orally disintegrating tab)
ST indicated
Also subject to QL (90 tablets/30 days); ST applies to ODT formulation and some titration packs per listing

Quantity Limit Examples & Defaults

Typical dispensing supply

Default supply30-day supply typical for outpatient prescriptions

Maintenance optionUp to 90-day supply allowed for maintenance medications where permitted by the plan

Exception processIf greater quantity is clinically necessary, provider may request an exception per plan procedures

Examples across formulary

Antibiotics (oral)Examples: azithromycin QL 60 tablets/180 days; clarithromycin ER QL 28 tablets/180 days; linezolid QL examples

Inhaled antibioticsTobramycin nebu soln QL 280 mLs/56 days or 224 mLs/56 days; TOBI PODHALER QL 224 capsules/56 days

Antivirals (HCV/HIV)Examples: BIKTARVY QL 30 tablets/30 days; EPCLUSA QL 28 tablets/28 days; VOSEVI QL 30 tablets/30 days

Specialty oncology/biologicsMany agents have QL and SP designations (examples in specialty sections)

BIKTARVY — Quantity limit

ProductBIKTARVY (bictegravir‑emtricitabine‑tenofovir AF)

Quantity limit30 tablets/30 days

Tier noteListed as Drug Tier = P in the formulary entry

EPCLUSA — Quantity limit

ProductEPCLUSA (sofosbuvir‑velpatasvir)

Quantity limit28 tablets/28 days (pellet pack also 28 packs/28 days)

Requirement flagsMarked PA and SP in Requirements/Limits column

RITONAVIR — Quantity limit

ProductRITONAVIR (Norvir) powder packets/tabulations

Quantity limit360 (packets/tablets)/30 days

Formulary noteListed as Drug Tier = NP in formulary entry

SUNLENCA — Quantity limit

ProductSUNLENCA (lenacapavir)

Quantity limit4 tablets/365 days (therapy pack variations shown)

PackagingTherapy pack configurations noted with specific QL per pack

VOSEVI — Quantity limit

ProductVOSEVI (sofosbuvir‑velpatasvir‑voxilaprevir)

Quantity limit30 tablets/30 days

Requirement flagsMarked PA and SP in Requirements/Limits column

Linezolid suspension — Quantity limit

Productlinezolid oral suspension 100 mg/5 mL (Zyvox)

Quantity limit600 mLs/180 days

TierListed as Drug Tier = NP

Linezolid tablets — Quantity limit

Productlinezolid tablet 600 mg (Zyvox)

Quantity limit56 tablets/180 days

TierListed as Drug Tier = NP

Vancomycin capsules — Quantity limit

Productvancomycin HCl capsules 125 mg / 250 mg (Vancocin)

Quantity limit120 capsules/30 days

Formulation noteOral capsule and oral solution forms listed with separate QLs

Rifaximin — Quantity limits

Productrifaximin 200 mg (XIFAXAN)

Quantity limit9 tablets/30 days

Alternate strengthrifaximin 550 mg QL 126 tablets/365 days

ALUNBRIG — Quantity limits

ProductALUNBRIG (brigatinib)

Quantity limits30 tablets/30 days for 90 & 180 mg strengths; initiation pack QL 30 tablets/180 days

Requirement flagsMarked PA and SP

BESREMI — Quantity limit

ProductBESREMI (ropeginterferon alfa‑2b)

Quantity limit2 syringes/28 days

Requirement flagsMarked PA and SP

IMBRUVICA (oral suspension) — Quantity limit

ProductIMBRUVICA oral suspension (ibrutinib)

Quantity limit216 mLs/30 days

Alternate formsCapsule QLs shown separately (30–90 capsules/30 days depending on strength)

MEKINIST — Quantity limit

ProductMEKINIST (trametinib) tablets — 0.5 mg

Quantity limit90 tablets/30 days (0.5 mg tab) per formulary entry

Requirement flagsMarked PA and SP for multiple MEKINIST formulations

PIQRAY therapy pack — Quantity limit

ProductPIQRAY therapy pack (alpelisib)

Quantity limit28 tablets/28 days (200 mg therapy pack example)

Requirement flagsMarked PA and SP

TAGRISSO — Quantity limit

ProductTAGRISSO (osimertinib)

Quantity limit30 tablets/30 days

Requirement flagsMarked PA and SP

VENCLEXTA — Quantity limit

ProductVENCLEXTA (venetoclax) 100 mg tabs

Quantity limit180 tablets/30 days (100 mg strength example)

Starter packStarting pack QL 1 pack/180 days for initiation

Prednisolone solution — Quantity limit

Productprednisolone sodium phosphate oral solution 10 mg/5 mL

Quantity limit900 mLs/30 days

Related entriesOther prednisolone/prednisone solutions/tabs show varying QLs by strength

Testosterone topical — Quantity examples

Product categoryTestosterone topical/gels — various formulations

Quantity examplesExamples vary by product: 30 packets/30 days; 2 bottles/30 days; 60 packets/30 days (per formulary entries)

AuthorizationMany entries list PA and specific QL values per formulation

MYFEMBREE — Quantity limit

ProductMYFEMBREE (relugolix‑estradiol‑norethindrone)

Quantity limit30 tablets/30 days

Requirement flagsMarked PA and QL in listing

ORIAHNN — Quantity limit

ProductORIAHNN (combined formulation)

Quantity limit56 capsules/28 days

Requirement flagsListed with AC and QL where indicated

RAYOS — Quantity limit examples

ProductRAYOS (prednisone delayed‑release)

Quantity limit examples90 tablets/30 days (1 mg); 60 tablets/30 days (2 mg); 360 tablets/30 days (5 mg)

TieringListed as NP+ for several strengths

JANUMET — Quantity limit

ProductJANUMET (metformin/sitagliptin combo)

Quantity limit60 tablets/30 days

Formulary noteQL shown in Requirements/Limits column

Metformin oral solution (Riomet) — Quantity limit

ProductMetformin oral solution (Riomet)

Quantity limit780 mLs/30 days

TieringListed as NP in formulary entry

Insulin products — Common QL

Product groupMultiple insulin products (e.g., HUMALOG, NOVOLOG, HUMULIN, NOVOLIN)

Common quantity limit100 mLs/30 days for many insulin formulations

NoteApplies across rapid‑acting, short‑acting and intermediate insulin listings as shown

MOUNJARO — Quantity limit

ProductMOUNJARO (tirzepatide)

Quantity limit4 pens/28 days or 4 pens/180 days depending on formulation/strength

Requirement flagsMarked PA and QL in formulary entries

OZEMPIC — Quantity limit

ProductOZEMPIC (semaglutide pen)

Quantity limit1 pen/28 days

Formulary noteListed with PA and QL in Requirements/Limits column

TRULICITY — Quantity limit

ProductTRULICITY (dulaglutide)

Quantity limit4 pens/28 days

TieringListed as P in formulary entries

Dispensing Channel & Site of Care Guidance

Note

Billing Rule

Dispense SP‑designated drugs via Specialty Pharmacy

Specialty agents designated 'SP' should be dispensed through the specialty pharmacy channel (Accredo or other specialty partner) where indicated; follow specialty routing instructions in the product entry.

Specialty pharmacy is required where SP is shown; several biologics and specialty agents are flagged SP in the listing.

Note

Key Terms & Abbreviations

Policy Background & Scope

Specialty drugs are used to treat complex conditions such as hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis and often require special handling or administration. When a medication is administered by a health care professional (for example, an infusion or in‑office injection), it may be billed under the medical benefit rather than the pharmacy benefit. Providers should confirm billing pathway and any specialty pharmacy routing (SP) indicated on the drug list prior to submitting claims.