2026 Drug List (preferred drug formulary)
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This document is Blue Cross and Blue Shield's 2026 Drug List describing preferred pharmacy drugs, specialty drug guidance, tiering, and coverage considerations for members and providers. It guides prescribing, prior authorization, step therapy, and dispensing limits for covered drugs.
No material clinical or coverage changes in this revision.
Coverage controls and requirements
General coverage controls
Coverage and management controls applied to drugs listed in this formulary:
See Special Requirements column and MyPrime.com for details
Tiering and ACA preventive coverage
Member cost and exceptions:
Tier placement may vary by benefit design; verify payment at MyPrime.com
General coverage rules for listed drugs
Coverage is product-specific; many high-cost agents require prior authorization and/or have quantity limits
Document lists which products are PA, QL, SP, or AC in-line; exact medical necessity criteria are not included in this section
Initial and Ongoing Coverage Requirements
Coverage requires meeting pharmacy prior authorization and quantity limit rules
Prescriptions exceeding the QL require justification documented in the prior authorization request
Non–FDA-approved drugs, repackaged medications, and some compounded medications are not covered under the pharmacy benefit. The document states that repackaged versions of medications already available on the market and drugs that have not received FDA approval are not covered, and that compounded medications may not be covered depending on the member's benefit plan. Providers and billing staff should verify coverage with the member's benefit materials or by calling the number on the member ID card when dispensing or billing these products.
Medications that must be administered by a health care professional (for example, injectables given in an office, infusion center, or hospital) are generally not covered under the pharmacy benefit and may be billed to the medical benefit instead. The policy instructs providers to check the benefit design and contact the number on the member ID card if a drug is not found on the drug list or if administration setting may affect coverage.
This segment contains no explicit clinical exclusions. The document does not list any medications or clinical scenarios that are declared excluded for clinical reasons within the provided excerpt.
There are no explicit statements in this segment labeling any therapy as 'not medically necessary.' The excerpt provided does not include NMN language or determinations of medical necessity stated in those terms.
Drug listings and code groups
| amoxicillin 250 mg, 500 mg (capsules) | amoxicillin (trihydrate) cap 250 mg, 500 mg |
| amoxicillin suspensions | amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml |
| amoxicillin tablets | amoxicillin (trihydrate) tab 500 mg, 875 mg |
| amoxicillin-clavulanate suspensions and tablets | amoxicillin & k clavulanate for susp 250-62.5 mg/5ml, 600-42.9 mg/5ml; tab 250-125 mg, 500-125 mg, 875-125 mg (Augmentin/es-600) |
| ampicillin cap 500 mg | ampicillin cap 500 mg |
| dicloxacillin capsules | dicloxacillin sodium cap 250 mg, 500 mg |
| cephalosporins list (examples) | cefadroxil, cefdinir, cefixime, cefpodoxime proxetil, cefprozil, cefuroxime axetil, cephalexin (various strengths and forms listed) |
| NDC-like/formulation entries | Extensive list of product formulations and strengths (e.g., amoxicillin trihydrate cap 250 mg, 500 mg; azithromycin tab 250 mg, 500 mg; fidaxomicin 200 mg; fluconazole tab 50 mg, 100 mg, etc.) as listed in document. |
| no CPT/HCPCS/ICD-10 codes present | Document section lists drug names, strengths, and requirement tags (PA, QL, SP) rather than procedure or diagnosis codes. |
| budesonide delayed release particles cap 3 mg | Entocort EC (listed repeatedly in the Requirements/Limits section) |
| testosterone td gel 12.5 mg/act (1%) | Androgel pump |
| testosterone td gel 20.25 mg/act (1.62%) | Androgel pump |
| testosterone td soln 30 mg/act | Axiron |
| ESTROGENS COMBIPATCH - estradiol-norethindrone | combination transdermal patch; dosing ranges noted (0.05-0.14 mg/day, 0.05-0.25 mg/day) |
| norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg | Femhrt low dose (drug name and strength as listed) |
Prior authorization, documentation, and prescribing actions
Obtain Prior Authorization for PA‑flagged drugs
Prescribers must submit a prior authorization (PA) request when a drug is flagged 'PA' in the Special Requirements column; coverage requires approval before the medication will be paid under the pharmacy benefit.
- PA is generally noted next to medications when commonly required.
PA required for select high‑cost agents
Certain high‑cost antiviral, antifungal, antimycobacterial, and antineoplastic agents are labeled PA and require prior authorization before coverage will be provided.
- Examples include posaconazole, bedaquiline, EPCLUSA (sofosbuvir‑velpatasvir), HARVONI, and multiple oncology agents listed with 'PA'.
PA required for specialty oral oncology agents
Many specialty oral oncology agents are designated PA (often alongside QL and SP); prescribers must obtain prior authorization for these products prior to dispensing.
- Examples include palbociclib (IBRANCE), imatinib (Gleevec), ibrutinib (IMBRUVICA), lenvatinib, and multiple other oncology oral agents listed with PA and SP.
PA required where shown with QL (example: 10 mls/28 days)
Some listed products show both a quantity limit and 'PA' (example entry adjacent to QL (10 mls/28 days) and PA); obtain PA when PA is indicated and adhere to the specified QL.
- If requesting quantities beyond the QL, submit justification within the PA request.
PA not specified for every entry in this excerpt
The 'Requirements/Limits' fragment lists products and dose ranges but does not provide an explicit PA workflow for every item; follow Special Requirements column and benefit materials for PA specifics.
- Refer to the Special Requirements column and member benefit materials for whether PA is required for a specific product.
Axiron: PA required and QL = 2 bottles/30 days
Testosterone topical solution (Axiron) is listed with PA and a quantity limit; prior authorization documentation must be submitted and claims should reflect the QL of 2 bottles per 30 days.
- Axiron strength listed as 30 mg/act; QL = 2 bottles/30 days.
Follow product‑specific PA and QL listings
The Requirements/Limits entries list product‑specific QL and PA indicators for topical testosterone and estrogen patch products; providers must follow those product limits when submitting claims or PA requests.
- Examples include Axiron (30 mg/act) and estradiol‑norethindrone patch dose ranges (0.05–0.25 mg/day).
Submit PA and respect QL when both are required
Where a product line shows 'PA, QL' (for example Axiron), providers must both obtain prior authorization and adhere to the listed quantity limit when filling the prescription.
- Claims should match the documented QL (e.g., 2 bottles/30 days) or include PA justification for excess.
Obtain PA when shown next to QL
Prior authorization is indicated alongside quantity limits in multiple listings; obtain PA when 'PA' appears next to the product or QL before dispensing.
- Listings show 'PA' next to QL entries (e.g., QL (10 mls/28 days) PA).
Formulary limits listed; PA criteria not detailed here
The document lists formulary entries and Requirements/Limits for products (e.g., Axiron and estrogen combipatch) but does not provide explicit clinical PA criteria in this segment; consult the payer or MyPrime for detailed PA criteria.
- Formulary lines include dose ranges and QLs but lack full medical necessity criteria in the excerpt.
QL = 30 patches/30 days for estrogen combipatch
A quantity limit of 30 patches per 30 days is specified for the estradiol‑norethindrone combination patch (Combipatch); claims exceeding this QL may be subject to denial without PA or supporting documentation.
- Combipatch listed with QL (30 patches/30 days).
Climara patches: QL 30 patches/30 days
Certain Climara transdermal estradiol patch strengths are subject to a quantity limit of 30 patches per 30 days; ensure prescribed days' supply and strength align with the QL when submitting claims or PA requests.
- Climara strengths listed (0.05, 0.06, 0.075, 0.1 mg/24hr) with QL = 30 patches/30 days.
PA may be required for requests exceeding QL
When requesting quantities beyond listed QLs (for example >30 patches/30 days), prior authorization may be required; submit documentation that supports the requested quantity.
- The policy notes prior authorization may be required if requesting quantities beyond the listed QL.
Femhrt low dose: PA required and QL 30/30 days
Femhrt (norethindrone acetate‑ethinyl estradiol 0.5 mg‑2.5 mcg) is listed as PA with a quantity limit of 30 tablets per 30 days; a lack of approved PA will result in denial of coverage for this product.
- Requirements/Limits: PA, QL (30 tablets/30 days) for Femhrt low dose.
Resubmit PA documentation for Femhrt (duplicate entry)
Femhrt low dose is repeated in the listing with PA and QL (30 tablets/30 days); providers must submit PA documentation for coverage and ensure claim quantity does not exceed the QL without justification.
- Failure to obtain PA will result in denial for Femhrt low dose.
Follow Step Therapy when 'ST' is indicated
Step therapy (ST) may be required for some products; if an ST is noted it will appear as 'ST' in the Special Requirements column and the member may need to try a specified alternative first.
- Refer to the Special Requirements column for an 'ST' designation and to member benefit materials for ST specifics.
Observe 'AC' / program codes and follow listed conditions
Some products are marked with administrative/approval codes (e.g., 'AC' or 'AC, QL') indicating additional coverage conditions; check the Special Requirements column and benefit materials for required actions.
- AC entries may relate to ACA preventive coverage or special cost‑sharing rules; follow instruction to submit copay waiver/coverage exception as applicable.
No explicit provider actions in this placeholder
No additional provider actions are specified in this empty placeholder section of the excerpt.
Consult PROVIDER ACTIONS fragments for PA/QL details
Providers should review the PROVIDER ACTIONS fragments in the policy for specific PA/QL instructions applicable to each drug line when preparing claims or prior authorization requests.
No ST specified unless marked 'ST'
No explicit step therapy requirements are detailed in many parts of this excerpt; if ST applies it will be noted with 'ST' next to the medication in the Special Requirements column.
- When ST is present, the member may need to try a specified alternative before the target medication is covered.
Check Special Requirements and benefit materials for required actions
Providers must use the Special Requirements column and member benefit materials to determine whether prior authorization, quantity limits, or step therapy apply for a given prescription.
No actions recorded
Empty placeholder — no provider actions are recorded in this part of the excerpt.
No step therapy sequences specified here
No step therapy sequences are provided in this text; providers should rely on the Special Requirements column and the member's benefit plan for any ST steps.
No provider actions in this fragment
Empty placeholder — no provider actions in this fragment of the document.
Submit PA where indicated in full listing
Fragment only — ensure to submit PA and documentation where 'PA' appears in the full Requirements/Limits listing.
Follow QL and PA notes in Requirements/Limits
Fragment only — follow product‑specific QL and PA notes in the Requirements/Limits table when completing prior authorizations or claims.
Adhere to PA and QL for specialty products
Fragment only — adhere to PA and QL shown for listed specialty products; obtain PA prior to dispensing when 'PA' is indicated.
No provider actions in this placeholder
Empty placeholder — no provider actions captured here.
Submit ACA copay waiver / coverage exception requests
ACA preventive medicine copay waiver or coverage exception requests may be submitted by the provider using forms available at bcbs.com/provider or myprime.com; decisions will be communicated to prescriber and member.
- Call the number on the member's ID card to request a review.
- Use provider forms available at the listed websites.
Document clinical need when requesting QL exceptions
When requesting an exception to a product's quantity limit, document the clinical indication and the quantity/days' supply requested to support the exception.
- Quantity limits are shown per product (e.g., QL (28 tablets/28 days)); include clinical rationale when requesting amounts beyond the QL.
Submit PA and bill according to listed QL
When a product line shows 'PA' and/or 'QL' providers must submit a prior authorization and ensure claims reflect the listed quantity limit units/duration.
- Submit PA when indicated and bill within the QL (units and time period) shown in the listing.
Provide documentation with PA submissions
Documented prior authorization is required for products labeled 'PA' (the policy shows PA inline with QL in some entries); include supporting clinical documentation with the PA submission.
- If a product shows 'PA' next to a QL, include clinical justification for the requested quantity.
No general documentation rules unless noted
No documentation requirements are specified in many product lines in this excerpt; where documentation is required it is noted alongside the PA/QL entries.
Axiron PA documentation and QL must be provided
For Axiron (testosterone topical solution), prior authorization documentation is required and the quantity limit of 2 bottles per 30 days should be reflected on the claim.
- Axiron listed as 30 mg/act with PA, QL (2 bottles/30 days).
Follow Requirements/Limits for documentation details
Fragment only — follow the Requirements/Limits table for specific documentation expectations when completing PA requests.
Ensure claims reflect documented QL (e.g., 2 bottles/30 days)
Documented quantity limits such as '2 bottles/30 days' should be reflected in the claim; include documentation when requesting quantities above the QL.
- Claims should align with the QL units/duration specified for the product.
Include clinical support when submitting PA for hormone products
When PA is indicated for testosterone topical solution or estrogen combipatch, supporting clinical documentation may be required as part of the PA review.
- Include indication, prior therapies (if relevant), and quantity/days' supply in the PA submission.
No provider actions in this fragment
Empty fragment — no provider actions specified in this excerpt portion.
Support patch quantity with dosing and days' supply
Documentation of requested quantity for patch products may be required to demonstrate adherence to the QL (e.g., 30 patches/30 days) and to justify larger requests.
- Provide dosing strength and intended days' supply to support the requested patch quantity.
Align dosing strength and days' supply with patch QL
Support patch quantity requests with documented dosing strength and intended days' supply that align with the listed strengths and the QL.
- Climara patch strengths and QL (30 patches/30 days) are included in the listing and should be matched by the prescription and documentation.
Include product, strength range, and QL in documentation
Required documentation elements for patch products include product name, strength range, and the designated quantity limit; include these in PA requests or when justifying exceptions.
- Examples: product name (Climara), strength (0.05–0.1 mg/24hr), QL (30 patches/30 days).
Provide PA documentation for PA‑labeled products
PA documentation is required for products labeled 'PA' in the Requirements/Limits table (for example Femhrt low dose); include necessary clinical details to support the request.
- Failure to provide PA documentation when required will result in denial.
Document clinical need when requesting PA for Femhrt
Prescribers should include clinical rationale supporting the need for Femhrt low dose when submitting PA, since PA is required for coverage of this product.
- PA and QL (30 tablets/30 days) are required for Femhrt low dose.
PA is required for some drugs — obtain approval before dispensing
Prior authorization is required for certain drugs; without an approved PA the medication may not be covered under the pharmacy benefit.
- If PA is commonly required it will be noted with 'PA' in the Special Requirements column.
Excess dispensing beyond QL may be billed to member
Dispensing quantities above posted quantity limits may result in the member being responsible for the full cost of the excess quantity and may trigger denial of coverage for that portion.
- For certain controlled substances state laws may also prohibit coverage beyond dispensing limits; check benefit and state rules.
Claims without PA for 'PA'‑flagged drugs may be denied
Drugs explicitly flagged 'PA' in the Requirements/Limits listing require prior authorization; claims submitted without PA may be denied.
Failure to obtain PA or SP may trigger denial
Claims for listed drugs that require prior authorization or specialty processing (SP) may be denied if the provider fails to obtain PA or arrange required specialty handling.
- SP designations indicate specialty pharmacy distribution/handling requirements.
When PA is shown with QL, secure PA and match approved quantity
Some entries show PA adjacent to a QL (for example QL (10 mls/28 days) PA); when PA is indicated alongside a QL, obtain PA before dispensing and ensure the claim quantity matches the approved amount.
No explicit denial triggers in every line — assume noncompliance risks
This section lists Requirements/Limits lines but does not state explicit denial triggers for every item; providers should assume PA or QL noncompliance can lead to denial where noted.
Axiron requests subject to PA and QL (2 bottles/30 days)
Requests for Axiron may be subject to prior authorization and a quantity limit of 2 bottles per 30 days; submit PA and document the requested quantity to avoid denial or member billing.
- Axiron: PA, QL (2 bottles/30 days).
Consult full table for product‑specific actions
Fragment only — consult the full Requirements/Limits table for explicit provider actions and denial risks related to each product line.
Obtain PA to avoid denials
Failure to obtain required prior authorization may result in denial of the claim for medications that are noted as PA; obtain PA prior to dispensing to avoid denials.
PA required as noted in Special Requirements
Prior authorization is required for multiple listed products; providers must follow the Special Requirements column and submit PA requests where shown.
Refer to Requirements/Limits for actions
Fragment only — refer to the Requirements/Limits entries for specific provider actions.
Requests over patch QL (30/30) may be denied
Requests exceeding the Climara/estrogen patch quantity limit (30 patches/30 days) may be denied if not supported by PA or clinical documentation.
- Ensure documentation explains the clinical need for quantities beyond the QL.
Climara QL enforcement — 30 patches/30 days
Quantity limits for Climara patches are enforced at 30 patches per 30 days; bill and dispense within that limit unless an approved PA supports a larger supply.
Exceeding QL without PA/documentation risks denial
Exceeding a listed quantity limit (for example >30 patches per 30 days) may trigger denial of coverage for the excess quantity unless an approved PA or appropriate documentation is provided.
PA + QL noncompliance may lead to denial
Where products are marked 'PA' and a QL is present (e.g., Femhrt or other PA‑flagged items), requests without PA or with quantities exceeding the QL may be denied.
Femhrt denial risk if PA not obtained
Lack of prior authorization when required for Femhrt low dose will result in denial of coverage for that product; obtain PA and include required documentation.
- Femhrt low dose: PA, QL (30 tablets/30 days).
Step therapy and utilization management
| Medication / Program | Special Requirements |
|---|---|
| When step therapy is commonly required for a medication, it will generally be noted with 'ST' in the Special Requirements column. | |
| Refer to your benefit plan materials for details; some plans may have additional ST requirements beyond those shown. |
| Medication / Program | Special Requirements |
|---|---|
| Selected antiviral agents and other products (examples in Requirements/Limits) are marked with program codes such as 'AC' indicating ACA preventive designation or other administrative codes. | |
| Entries such as DESCOVY and Truvada show 'AC' alongside QL (30 tablets/30 days) in the Requirements/Limits listing. |
| Product | Management Flags |
|---|---|
| Testosterone topical products (Androgel pumps; Axiron topical solution) | |
| Management: PA indicated for Axiron; QL examples shown (Axiron: QL 2 bottles/30 days). | |
| ESTROGENS COMBIPATCH (estradiol-norethindrone ace transdermal patch) | |
| Management: PA indicated where shown; patch QL commonly listed as QL (30 patches/30 days) for patch products (Climara examples). |
| Drug / Product | Coverage Status |
|---|---|
| Selected high-cost antiviral, antifungal, antimycobacterial, and antineoplastic agents listed with 'PA' in Requirements/Limits | |
| Many specialty oral oncology agents (examples in listings) are denoted 'PA' and require prior authorization before coverage |
Specified quantity limits and typical supplies
Administration site and benefit assignment
Provider‑administered drugs may be covered under medical benefit
Medications that must be administered by a health care professional may be covered under the medical benefit rather than the pharmacy benefit; check site‑of‑care rules for infusion/clinic‑administered drugs.
- Provider‑administered drugs may be billed to medical benefit
- Examples include certain injectables and chemo infusions
Terms and abbreviations
Quick code and drug lists
| Special Requirement | Presence |
|---|---|
| ST (Step Therapy) | |
| PA (Prior Authorization) | |
| QL (Quantity Limit) | |
| AC (ACA preventive) |
| Product | Requirements / Quantity Limit |
|---|---|
| Testosterone td soln 30 mg/act (Axiron) | |
| PA required; QL: 2 bottles per 30 days (documented in Requirements/Limits). | |
| ESTROGENS COMBIPATCH - estradiol-norethindrone ace transdermal patch | |
| QL: 30 patches per 30 days (patch QL indicated); PA shown where specified in listing. | |
| Climara transdermal estradiol patches (examples: 0.05–0.1 mg/24hr strengths) | |
| QL: 30 patches per 30 days (documented QL for patch strengths). | |
| Norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg (Femhrt low dose) | |
| PA required; QL: 30 tablets per 30 days (Requirements/Limits). |
| Drug (listed) | NDC / Description |
|---|---|
| norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg | |
| Femhrt low dose — Requirements/Limits: PA, QL (30 tablets/30 days) |
Context and scope
Specialty drugs are therapies used to treat complex conditions such as hepatitis, hemophilia, multiple sclerosis, and rheumatoid arthritis and can be oral, topical, or injectable. Many specialty agents require management controls including prior authorization (PA), quantity limits (QL), and specialty distribution (SP) designations; these controls and tier placement are used to ensure appropriate clinical use and to align benefits with FDA labeling and evidence-based guidance. Provider billing and clinical staff should note that specialty drugs administered by a health care professional may be billed to the medical benefit rather than the pharmacy benefit and that formulary-specific requirements (PA, QL, ST) are listed alongside product entries.
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