Blue Cross and Blue Shield of New Mexico Drug List (Formulary) — Coverage Criteria
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Governs which prescription and specialty drugs BCBSNM will cover for members, describes member responsibilities, prior authorization, quantity limits, step therapy, specialty pharmacy rules, and exclusions. Affects BCBSNM members and their prescribing providers and pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria and Formulary Controls
Standard coverage conditions
Covered when ALL of the following are met
Sources: [[chunk 1]], [[chunk 14]]
Sources: [[chunk 10]], [[chunk 14]]
Source: [[chunk 12]]
General formulary coverage
Coverage is conditioned on plan-tier rules and utilization controls as annotated per drug entry (PA, QL, SP, SF, 90-day mail).
Sources: [[chunk 126]], [[chunk 144]]
Formulary coverage with utilization controls
Formulary coverage with utilization controls; coverage depends on tier and any indicated utilization control.
Examples: REPATHA (PA, QL), ORENITRAM (PA, QL, SP), UPTRAVI (PA, QL, SP). Sources: [[chunk 144]], [[chunk 152]], [[chunk 153]]
Formulary tiering and restrictions
Medications are assigned coverage tiers and may have PA, QL, age limits, or specialty flags as indicated below.
Examples: alprazolam entries with QL; EMSAM patch with PA and 90-day mail flag; aripiprazole long‑acting injectables with PA and QL. Sources: [[chunk 180]], [[chunk 186]], [[chunk 193]]
General coverage conditions
Coverage is subject to product-specific utilization management as listed below
Sources: [[chunk 198]], [[chunk 212]]
Per-product coverage controls
Coverage and utilization controls are applied per-product; common controls include:
Sources: [[chunk 218]], [[chunk 220]], [[chunk 233]]
Coverage conditioned on per-product utilization controls
Products listed with assigned tier levels and specific utilization management actions; coverage conditioned on meeting any listed control (PA/QL/SP).
Examples and legends appear in the drug list; see specific entries for the exact controls. Sources: [[chunk 252]], [[chunk 260]], [[chunk 271]]
The formulary explicitly lists categories that are not covered. Examples include anorexia/weight loss or gain drugs, bulk chemicals, cosmetic enhancing drugs, diagnostic agents, DESI (Drug Efficacy Study Implementation) drugs, experimental or investigational drugs, fertility drugs, general anesthetic drugs, erectile dysfunction drugs prescribed to treat impotence, opioid cough and cold products (excluded for ages <18), over‑the‑counter products not on the plan drug list, and surgical supplies/medical devices.
In the provided vaccine and related product segments there are no additional broad exclusion categories stated; entries focus on product‑level controls such as quantity limits (e.g., SHINGRIX QL = 2 per lifetime) and tier assignments rather than an explicit exclusion list in these chunks.
These formulary product segments do not contain a separate, overarching exclusions statement. Coverage descriptors are presented as per‑product annotations (e.g., PA, QL, SP, SF) and no explicit exclusions language appears in these chunks.
Within this cardiology/related drug listing excerpt no distinct exclusions list is provided. The text indicates per‑product operational flags (for example, mail‑order day supply markers) but does not enumerate excluded categories in these chunks.
This section lists per‑product quantity limits and tiering for CNS agents but contains no explicit statement declaring additional excluded drug categories; controls are applied at the product level (e.g., QL) rather than via an exclusions list in this excerpt.
The long‑acting injectable and mood‑stabilizer listings describe utilization controls (for example, PA and QL for INVEGA TRINZA) but do not include a separate exclusions enumeration in this excerpt.
The prenatal vitamins and minerals segment lists product entries and any product‑level limits; it does not present an explicit exclusions list within these chunks.
No 'not medically necessary' determinations are stated in these product listing chunks; the content is limited to formulary flags (e.g., PA, QL, SP) and quantity/tier information without explicit NMN language.
The respiratory/inhaled therapy excerpts include age‑based PA and quantity limits but do not contain explicit 'not medically necessary' findings; restrictions are described as utilization controls rather than NMN determinations.
In this excerpt of CNS product entries there are no explicit 'not medically necessary' determinations; the entries specify tiering and quantity limits (QL) instead of NMN language.
The antipsychotic/long‑acting injectable listings indicate PA and QL requirements but do not include explicit statements labeling therapies as 'not medically necessary' within these chunks.
The minerals, prenatal vitamin and related listings show product‑level information and necessary actions but do not present explicit 'not medically necessary' statements in the provided segments.
Formulary Product Listings, Flags, and Key Values
| GENVOYA | elvitegrav-cobic-emtricitab-tenofov af tab 150-150-200-10 mg |
| ISENTRESS | raltegravir potassium tabs/chew/packet (various strengths) |
| JULUCA | dolutegravir sodium-rilpivirine hcl tab 50-25 mg |
| KALETRA | lopinavir-ritonavir soln/tab (various strengths) |
| lamivudine | oral solution and tablets (Epivir) 10 mg/ml, 150 mg, 300 mg |
| maraviroc | Selzentry tabs/solution 150 mg, 300 mg; oral soln 20 mg/ml |
| NEVIRAPINE | nevirapine susp/tab (Viramune) |
| NORVIR | ritonavir powder packet 100 mg |
| STRIBILD | elvitegrav-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg |
| SUNLENCA / YEZTUGO | lenacapavir sodium tab 300 mg (therapy packs and single tablets) |
| FLUZONE HIGH-DOSE 2025-2026 | influenza virus vac split high-dose pf susp pref syr 0.5ml |
| FLUZONE 2025-2026 | influenza virus vaccine split im susp |
| GARDASIL 9 | human papillomavirus (hpv) 9-valent recomb vac |
| HAVRIX | hepatitis a vaccine susp prefilled syr |
| HEPLISAV-B | hepatitis b vaccine recomb adjuvanted pref syr 20 mcg/0.5ml |
| SHINGRIX | zoster vac recombinant adjuvanted for im inj 50 mcg/0.5ml |
| SPIKEVAX | covid-19 mrna vaccine-moderna im susp pref syr 50 mcg/0.5ml |
| PNEUMOVAX 23 | pneumococcal vaccine polyvalent soln pref syr 25 mcg/0.5ml |
| abiraterone acetate 250 mg (Zytiga) | oral tablet - oncology |
| ALECENSA | alectinib hcl cap 150 mg |
| AUGTYRO | repotrectinib cap 40 mg / 160 mg |
| IBRANCE | palbociclib cap/tab 75/100/125 mg |
| IMBRUVICA | ibrutinib cap 140 mg / oral suspension |
| dasatinib (Sprycel) | dasatinib tabs various strengths |
| gefitinib tab 250 mg | Iressa; Tier Level = 1; QL (30 tablets/30 days), SF, SP |
| afatinib dimaleate tab 20 mg, 30 mg, 40 mg | GILOTRIF; Tier Level = 2; QL (30 tablets/30 days), SP |
| mirdametinib cap/tab 1-2 mg | GOMEKLI; Tier Level = 2; QL varying (168 tablets/28 days or 84 capsules/28 days), SP |
| topotecan hcl cap 0.25 mg, 1 mg | HYCAMTIN; Tier Level = 2; SP |
| hydroxyurea cap 500 mg | Hydrea; Tier Level = 1 |
| palbociclib cap/tab 75 mg, 100 mg, 125 mg | IBRANCE; Tier Level = 2; QL (21 caps/tablets/28 days), SP |
| taletrectinib adipate cap 200 mg | IBTROZI; Tier Level = 2; QL (90 capsules/30 days), SP |
| ponatinib hcl tab 10 mg, 15 mg, 30 mg, 45 mg | ICLUSIG; Tier Level = 2; QL (30 tablets/30 days), SF, SP |
| imatinib mesylate tab 100 mg, 400 mg | Gleevec; Tier Level = 1; QL (90 tablets/30 days for 100 mg; 60 tablets/30 days for 400 mg), SF, SP |
| ibrutinib cap/oral susp 140 mg / 70 mg/ml | IMBRUVICA; Tier Level = 2; QL (90 caps/30 days or 216 mL/30 days), SP |
| drug names and strengths | Multiple listed products with strengths (e.g., TAGRISSO - osimertinib 40 mg, 80 mg; TALZENNA - talazoparib 0.25 mg ...) |
| QL (360 tablets/30 days) | acarbose 25 mg — quantity limit |
| QL (180 tablets/30 days) | acarbose 50 mg — quantity limit |
| QL (90 tablets/30 days) | acarbose 100 mg — quantity limit |
| ST | Step therapy flag (appears on alogliptin products and others) |
| 90 | 90 days available at mail order |
| QL (30 tablets/30 days) | alogliptin formulations — quantity limit |
| QL (60 tablets/30 days) | alogliptin-metformin formulations — quantity limit |
| QL (6 packs/365 days) | Baqsimi nasal glucagon — quantity limit |
| DX | Diagnosis required (e.g., liraglutide, OZEMPIC) |
| PA | Prior authorization required |
| N/A | Drug names and strengths listed (no CPT/HCPCS/ICD codes in these chunks) |
| No codes listed |
| No codes listed |
| INVEGA TRINZA - paliperidone palmitate er susp pref syr 273 mg/0.88ml, 410 mg/1.32ml, 546 mg/1.75ml, 819 mg/2.63ml | Tier Level = 2; PA, QL (1 syringe/84 days) |
| lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg (Latuda) | Tier Level = 1; QL (30 tablets/30 days), 90 |
| paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg (Invega) | Tier Level = 1; PA, QL (30 tablets/30 days), 90 |
| quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg (Seroquel xr) | Tier Level = 1; PA, QL (60 tablets/30 days), 90 |
| REXULTI - brexpiprazole tab 0.25 mg to 4 mg | Tier Level = 2; PA, QL (30 tablets/30 days), 90 |
| risperidone microspheres for im extended rel susp (Risperdal consta) 12.5 mg to 50 mg | Tier Level = 1; PA, QL (2 vials/28 days) |
| UZEDY - risperidone subcutaneous er susp pref syr 50 mg to 125 mg and 150 mg to 250 mg | Tier Level = 2; PA, QL (1 syringe/28 or 56 days) |
| VERSACLOZ - clozapine susp 50 mg/ml | Tier Level = 2; PA, QL (540 mls/30 days) |
| VRAYLAR - cariprazine hcl cap 1.5 mg to 6 mg | Tier Level = 2; PA, QL (30 capsules/30 days), 90 |
| ZYPREXA RELPREVV - olanzapine pamoate for extended rel im susp 210 mg, 300 mg, 405 mg | Tier Level = 2; PA, QL (1-2 vials/28 days) |
| ME90 | Morphine Equivalent |
| PA | Prior Authorization |
| QL | Quantity Limits |
| SP | Specialty |
| AL | Age Limit |
| ST | Step Therapy |
| PA | Prior Authorization |
| QL | Quantity Limits |
| SP | Specialty |
| AL | Age Limit |
| ST | Step Therapy |
| DX | Diagnosis Required |
| 90 | 90 days available at mail order |
| SF | Split Fill |
| ME90 | Morphine Equivalent |
Prior Authorization, Step Therapy, Documentation, and Denial Risks
Prior authorization required for PA‑marked and specialty drugs
Certain medications listed on the drug list that are annotated with the code 'PA' require prior authorization before BCBSNM will cover the drug; specialty drugs also require prior authorization and must be obtained from a participating specialty supplier (Accredo preferred). If prior authorization is not obtained, BCBSNM may not pay for the drug.
- PA appears in the 'Necessary actions, restrictions, or limits on use' column to indicate prior authorization is required.
- Specialty drugs require PA and must be filled by an in‑network specialty supplier (Accredo preferred); limited distribution pharmacies may be used if Accredo cannot supply.
Obtain PA when 'PA' or 'SP' is indicated
Products flagged with 'PA' or with specialty designation ('SP') in the formulary legend will trigger prior authorization and specialty pharmacy workflows; providers must obtain authorization per plan rules before dispensing.
- PA and SP flags in the formulary legend indicate required authorization or specialty handling.
- Examples in the list (e.g., CAYSTON) show SP with QL and PA where applicable.
Prior authorization applies where PA/SP flags appear
Where a product is annotated with 'PA' or 'SP' next to the drug entry, prior authorization must be obtained; the formulary legend uses these flags to indicate the need for authorization or specialty routing.
- Legend abbreviations include PA = Prior Authorization and SP = Specialty.
- When 'PA' appears in the product entry, prior authorization is required before coverage is approved.
Obtain prior authorization when 'PA' is indicated
If 'PA' is present in the 'Necessary actions, restrictions, or limits on use' column for a product, providers must obtain prior authorization before BCBSNM will cover the drug; failure to get PA may result in non‑payment.
- PA is the formulary marker that indicates prior authorization is required for coverage.
- Contact Member Services for instructions on submitting a PA or use the coverage exception form on MyPrime.com.
Prior authorization required for listed PA drugs (examples)
Many listed drugs explicitly include 'PA' in their product entry (examples across the list); providers must secure prior authorization for those listed agents before dispensing.
- Examples: danazol and various testosterone products are listed with PA.
- Agents such as liraglutide (Victoza), OMNITROPE, ACTHAR, MYALEPT, and ORILISSA are annotated PA in their entries.
PA required for select specialty/brand agents (Victoza, somatropin, ACTHAR)
Specific high‑cost and specialty agents in the formulary are listed with PA; providers must obtain prior authorization for these medications (examples include liraglutide/Victoza, somatropin/OMNITROPE, and ACTHAR).
- Victoza (liraglutide) — DX, PA, QL noted in entry.
- OMNITROPE (somatropin) and ACTHAR are shown with PA and SP where applicable.
Prior authorization required for multiple specialty products
Multiple specialty products and biologics are annotated 'PA' in the drug list; providers must secure prior authorization for these specialty agents prior to coverage (examples include MYALEPT, ORILISSA, sapropterin/Kuvan, tolvaptan/Samsca, REPATHA).
- These entries show PA and often SP and QL alongside the product.
- Providers should confirm PA requirements for each formulation listed.
PA for selected psychotropic and long‑acting injectable products
Prior authorization is required for certain specialty and psychotropic products and for long‑acting injectable antipsychotics where 'PA' appears in the entry (examples include EMSAM, FETZIMA, ABILIFY ASIMTUFII, ARISTADA, INVEGA SUSTENNA/TRINZA).
- Long‑acting injectables list PA and specific QLs (e.g., 1 syringe/28 days or 1 syringe/84 days for INVEGA TRINZA).
- Brand/ER formulations may also be annotated PA.
PA required for numerous listed products (examples)
The formulary contains many PA‑marked products across therapeutic classes; providers must obtain prior authorization for those items before BCBSNM will cover them.
- Examples include REPATHA (PA, QL), ADEMPAS, ambrisentan, bosentan, ORENITRAM, TYVASO, UPTRAVI which show PA in their entries.
- Check each product entry for PA and associated QL or SP requirements.
PA required for PA‑marked products (QVAR RediHaler, TRELEGY)
Products marked 'PA' in the formulary (e.g., QVAR RediHaler, TRELEGY ELLIPTA) require prior authorization; providers should obtain PA and note any age‑based PA where indicated.
- QVAR REDIHALER entries include PA (>=12 yr) and QL requirements.
- TRELEGY ELLIPTA is listed with PA and QL (1 inhaler/30 days).
PA required for selected psychotropic and LA injectables
Selected psychotropic brand products and long‑acting injectable antipsychotics require prior authorization as indicated by PA next to the product; obtain PA before dispensing to avoid coverage denial.
- Examples include EMSAM (PA), ARISTADA (PA, QL), ABILIFY MAINTENA (PA, QL).
Obtain PA for age‑limited products
Many products include age‑based PA notations; where age limits or age‑based PA appear (e.g., PA (<=5 yr), PA (<=17 yr)), providers must obtain prior authorization in accordance with those age restrictions.
- Aripiprazole products show PA (<=5 yr) for some formulations; multiple other agents have AL or age‑based PA noted.
- Failure to obtain required age‑based PA may result in denial.
Opioid PA tied to ME90 and opioid limits
Opioid products are annotated with ME90 (morphine equivalent) and, when dosing exceeds ME90 or other opioid limits apply, prior authorization is required; opioid‑naive initial IR supply limits also apply.
- ME90 = current daily morphine equivalent limit of 90 mg per day in New Mexico; doses above ME90 require PA.
- Opioid‑naive members are limited to a seven‑day supply of immediate‑release opioids for their first fill.
PA required for migraine biologics and other specialty biologics
PA is required for certain specialty biologics including multiple migraine preventive biologics; providers must obtain PA for agents such as AIMOVIG, AJOVY, and EMGALITY before coverage.
- AIMOVIG, AJOVY, EMGALITY entries show PA and specific QLs (e.g., AIMOVIG QL 1 syringe/28 days; EMGALITY QL 1 syringe/28 days or 9 syringes/180 days).
- Lack of PA for these specialty biologics may result in non‑coverage.
PA applies to listed specialty and brand products (examples)
Prior authorization applies to many brand and specialty products listed with 'PA' in their entry; providers must obtain PA for those products (examples include EMGALITY products, LAMICTAL XR kits, certain hormone and metabolic agents).
- EMGALITY prefilled syringes and auto‑injectors show PA and QL requirements.
- LAMICTAL XR starter kits are noted with PA in product entries.
PA required for many specialty/injectable and factor products
Many injectable, high‑cost, or specialty factor products are annotated 'PA' and 'SP'; providers must obtain prior authorization for these specialty/injectable products prior to dispensing (examples: ADVATE, ADYNOVATE, HAEGARDA, BERINERT).
- Hemophilia and coagulation factors (ADVATE, ADYNOVATE, ALPHANATE, ALPHANINE SD) list PA and SP.
- HAEGARDA and BERINERT show PA with specific QLs.
Step therapy applies where 'ST' is marked; request exceptions if unmet
Some drugs are subject to step therapy (marked 'ST'); if the required step therapy has not been met, providers or members may request a step therapy exception through Member Services.
- Step therapy is identified by 'ST' in the formulary and requires trying specified first‑line agents before coverage for later agents.
- To request an exception, contact BCBSNM Member Services at 1‑866‑689‑1523.
Confirm step therapy for ST‑flagged products
The formulary marks some drugs/classes with 'ST' (step therapy); providers must confirm and meet step therapy requirements for products annotated with ST before coverage is approved.
- Examples: alogliptin products and certain SGLT2/DPP‑4 combinations are shown with ST.
- Legend includes ST = Step Therapy to indicate where step edits apply.
ST legend: step therapy indicated where 'ST' appears
The formulary legend defines 'ST = Step Therapy'; when ST appears next to a product, step therapy requirements must be followed though specific per‑drug step sequences are not listed in this excerpt.
- ST is part of the formulary abbreviation legend and indicates a step requirement may apply.
- Providers should review product entries and contact Member Services for step‑therapy details or exception processes.
PA and age/Q L requirements for select inhaled products
When 'PA' is shown next to specific drugs (e.g., QVAR RediHaler, TRELEGY ELLIPTA), providers must obtain prior authorization and observe any age limits or QLs noted in the entry.
- QVAR REDIHALER entries indicate PA (>=12 yr) and specific QLs (1–2 inhalers/30 days).
- TRELEGY ELLIPTA is listed PA with QL (1 inhaler/30 days).
ST applies to specific agents (e.g., alogliptin, STEGLATRO)
Step therapy is referenced in the formulary legend and applies to some products (examples: alogliptin products, STEGLATRO/ertugliflozin) where ST appears; providers must follow step edits where applied.
- Alogliptin and its combinations are annotated ST and QL in product entries.
- STEGLATRO entries include ST for certain strengths.
Step therapy required for select DPP‑4/SGLT2 and combination agents
Step therapy requirements are shown for several combination and DPP‑4/SGLT2 agents (e.g., alogliptin products, ertugliflozin/Steglatro); providers must confirm the member has met required prior steps or request an exception.
- Entries indicate ST alongside QL and 90‑day mail flags where applicable.
- If step therapy is unmet, contact Member Services for exception procedures.
Legend notes ST = Step Therapy; check product specifics
The formulary legend includes ST = Step Therapy, but specific step‑by‑step rules for individual drugs are not provided in this excerpt; providers should check product entries or contact Member Services for details.
- ST appears across the legend and multiple product entries but per‑drug step sequences are not shown here.
- Providers may need to query plan resources for the exact step pathway.
How to submit prior authorization (fax/phone/online)
Providers may submit prior authorization (coverage exception) requests by fax to 1‑877‑243‑6930, by phone to 1‑800‑285‑9426 (TTY/TDD 711), or online via MyPrime.com or CoverMyMeds.com.
- Use the coverage exception request form available on MyPrime.com.
- Phone and fax options are provided for prescribers to submit PA requests.
Contact Member Services for PA/coverage questions
For questions about drug coverage, authorization processes, or to initiate exceptions, members or providers should contact BCBSNM Member Services at 1‑866‑689‑1523 (TTY/TDD 711).
- Member Services is available Monday–Friday, 8:00 a.m. to 5:00 p.m. Mountain time.
- Member Services can advise on PA, step therapy exceptions, or quantity‑limit exceptions.
Ensure claims reflect listed QL and day‑supply
Pharmacy claims must reflect the product and days' supply consistent with the listed quantity limits (QL) and mail‑day supply rules; submitting claims that exceed QL or incorrect day‑supply may lead to denial or adjustment.
- Examples: GENVOYA QL (30 tablets/30 days); many oral products have 90‑day mail‑order availability noted.
- Claims should use the days' supply and quantity that match the formulary QL.
Specialty drugs: follow QL and SP handling
Specialty‑designated products (SP) must follow the specialty dispensing and quantity‑limit rules; providers should expect specialty pharmacy handling, documentation, and routing for SP products.
- Specialty drugs are handled through the BCBSNM network specialty supplier (Accredo preferred).
- SP entries often include QL and PA requirements; follow specialty pharmacy submission processes.
Provide required documentation for flagged controls (PA, DX, SP, etc.)
Formulary entries use shorthand flags (PA, QL, SF, SP, ST, DX, AL) to indicate required administrative controls; providers must supply required documentation when those flags appear (e.g., DX = diagnosis required, PA = prior authorization).
- DX indicates a diagnosis is required for coverage.
- SF indicates split‑fill; ST indicates step therapy; AL indicates age limits.
Refer to formulary legend for PA/QL/SP/ST/DX/AL meanings
The formulary legend defines operational abbreviations used across entries (PA = Prior Authorization, QL = Quantity Limits, SP = Specialty, ST = Step Therapy, DX = Diagnosis Required, AL = Age Limit, 90 = 90‑day mail order).
- Use the legend to interpret per‑product controls and submission needs.
- These abbreviations indicate actions that must be completed to secure coverage.
Supply diagnosis documentation when 'DX' or PA is required
Products annotated 'DX' require an associated diagnosis to be documented when seeking PA or coverage; prescribers must supply diagnosis documentation where 'DX' appears.
- Examples: Victoza and other agents include DX with PA and QL flags where diagnosis may be needed.
- Documentation supporting the clinical indication should be included with PA requests.
Prescribers must supply clinical documentation for PA
For drugs marked 'PA' providers must submit supporting clinical documentation to meet the prior authorization requirements (examples: ADEMPAS, ambrisentan, bosentan, ORENITRAM, TYVASO, UPTRAVI).
- Include clinical rationale and any prior step failures or contraindications when requesting PA.
- Member Services or the PA submission portals can confirm required documentation elements.
Obtain PA prior to dispensing; observe age‑based PA notes
For products marked 'PA' the provider must obtain prior authorization before dispensing; age‑based PA notes appear for some products (e.g., PA (<=5 yr) for certain aripiprazole formulations, PA (<=17 yr) for some opioid entries).
- Aripiprazole products list PA with specific pediatric age limits.
- Opioid entries include ME90 and PA (<=17 yr) for certain formulations.
Risk of denial for exceeding quantity limits (QL)
Claims that exceed stated quantity limits (QL) are at risk for denial or require a quantity‑limit exception; providers should confirm QL in the product entry and request a QL exception if clinically necessary.
- Examples of QL exceedance risks: QL 90 syringes/30 days, QL 2 syringes/28 days, QL 240 capsules/30 days.
- SHINGRIX is limited to QL 2 vaccines per lifetime.
Denial risk if PA or specialty requirements are not met
Coverage may be denied when a drug is designated PA or SP and the necessary prior authorization or specialty authorization is not obtained; providers should secure PA for PA‑marked products to avoid denial.
- PA+SP entries (e.g., Repatha, ORENITRAM) require authorization and adherence to QL/SP rules.
- Failure to obtain PA for PA‑marked drugs may lead to non‑coverage.
Initial Therapy and Specialty Split-Fill
Specialty Split Fill — Specialty Pharmacy Split Fill Program for new specialty drug starts
Specialty Pharmacy Split Fill Program for new specialty drug starts
Source: [[chunk 12]]
Long-acting injectables — selected long-acting injectable and ER antipsychotics
Selected long-acting injectable and extended release antipsychotics
Examples: ABILIFY MAINTENA, ARISTADA, INVEGA TRINZA, RISPERDAL CONSTA, UZEDY — see individual entries for PA and QL values. Sources: [[chunk 193]], [[chunk 198]], [[chunk 201]], [[chunk 203]]
Step Therapy Controls and Notation
| Coverage label | Description |
|---|---|
| ST | |
| Step therapy applies to some drugs identified by 'ST' in the drug list; medications subject to step therapy are identified by an 'ST' in the 'Necessary actions, restrictions, or limits on use' column and must meet required prior steps or obtain an exception for coverage. |
| Flag | Meaning / use in formulary |
|---|---|
| ST | |
| Indicates the product is subject to Step Therapy; listed next to specific drug formulations where the plan requires trying specified first-line agents before covering the listed agent. |
| Legend code | Definition |
|---|---|
| ST | |
| ST = Step Therapy (appears in the formulary legend as a possible utilization control). |
| Product | ST noted? |
|---|---|
| Alogliptin (e.g., alogliptin, alogliptin/metformin, alogliptin/pioglitazone) | |
| Yes — entries include 'ST' alongside QL and 90-day mail flags for alogliptin formulations. |
| Observation | Source notes |
|---|---|
| ST appears in the legend as an available control | |
| Multiple legend excerpts show ST = Step Therapy, but this document excerpt does not include full, drug-specific step-path requirements or step-edit logic. |
| Product | ST flag present? |
|---|---|
| Alogliptin (alogliptin benzoate and combinations) | |
| Marked with ST in formulary entries (ST present with QL and 90 flags). |
| Agent / class | Step therapy requirement (as shown) |
|---|---|
| Alogliptin products | |
| Listed with QL and ST — step therapy applies prior to coverage unless an exception is obtained. |
| Legend entry | Implication |
|---|---|
| ST = Step Therapy | |
| Legend shows ST as a control code; no step paths or detailed algorithm are provided in this excerpt. |
| Reference | Content |
|---|---|
| Formulary legend examples | |
| Abbreviations listed in legend include ST = Step Therapy alongside PA, QL, SP, SF, AL, DX, 90, and ME90. |
| Reference | Policy statement |
|---|---|
| Step therapy as a control | |
| When a drug is subject to step therapy (ST), members or providers may request a step therapy exception via Member Services if required steps have not been met. |
| Legend code | Interpretation |
|---|---|
| ST | |
| Step Therapy (ST) is referenced in the formulary legend as an available utilization control; specific step requirements are not enumerated here. |
| Legend item | Note |
|---|---|
| ST = Step Therapy | |
| Listed with other control codes; treatment exceptions and Member Services contact information are provided elsewhere for ST exceptions. |
| Notation | Presence in excerpt |
|---|---|
| ST | |
| Step therapy notation appears repeatedly in legend excerpts but no per-drug step paths are included in these chunks. |
| Legend/code | Comment |
|---|---|
| ST | |
| Defined in the legend as Step Therapy; the excerpt does not show the detailed step requirements for specific drugs beyond flagging (e.g., alogliptin entries show ST). |
| Legend | Detail level |
|---|---|
| ST = Step Therapy | |
| Legend includes ST but the document excerpt does not provide step sequences or decision logic for ST-marked agents. |
Quantity Limits and Day-Supply Examples
Specialty Distribution and Administration Sites
Accredo preferred for specialty dispensing
Accredo is the preferred in‑network specialty pharmacy for BCBSNM specialty drugs; limited distribution pharmacies are used when Accredo cannot supply the product.
SP products may require specialty site of care
Some SP‑flagged products (e.g., CAYSTON) may require specialty pharmacy dispensing or have site‑of‑care implications such as infusion center or home administration.
SP designation implies specialty handling
Specialty designation (SP) indicates specialty handling, potential site‑of‑care controls, and may require specialty pharmacy documentation and routing.
LA injectables imply clinical administration and PA
Long‑acting injectable (LAI) agents listed with syringe/kit QLs and PA imply administration in a clinical setting (infusion center or office); providers should plan for prior authorization and appropriate site‑of‑care billing.
MS agents: infusion/office/SP handling
Some multiple sclerosis agents and other SP‑designated drugs may be managed through infusion center, office administration, or specialty pharmacy channels and require QL and SP compliance.
Specialty pharmacy management for SP items
Products designated 'SP' are managed through specialty pharmacy programs and require specialty documentation, routing, and adherence to QL and PA controls.
SP designation common for injectable/coagulation products
Many injectable and coagulation products are designated 'SP' and will follow specialty pharmacy distribution and documentation practices.
Biosimilar Notes and Examples
Adalimumab QL and SP handling
Adalimumab biosimilars and reference products carry QL and SP flags (e.g., QL 2 syringes/28 days) — ensure claims reflect the listed quantity limits and specialty handling.
Adalimumab: QL (2 syringes/28 days), SP
Adalimumab entries show QL (2 syringes/28 days) and SP designation; providers must adhere to these limits and specialty routing when prescribing or billing.
Biosimilar adalimumab: QL and SP noted
Adalimumab biosimilar entries repeat QL and SP requirements (e.g., 2 syringes/28 days) — claims and dispensing must conform to these controls.
Background and Scope
Background: Specialty drugs are prescription medications used to treat complex, chronic conditions that often require special handling (for example, refrigeration), specialized administration (injection or infusion), and care coordination. The formulary applies per‑product utilization management such as Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), and Specialty (SP) routing. For opioid safety the plan uses a morphine‑equivalent threshold (ME90) and an initial immediate‑release opioid supply limit for opioid‑naive members of 7 days. Specialty drugs frequently must be dispensed by a participating specialty supplier (Accredo preferred) and the formulary implements a Specialty Pharmacy Split Fill Program to manage initial specialty dispensing.
Definitions and Formulary Abbreviations
Key Contacts and How to Request Authorization
PA submission channels (fax/phone/online)
Submit PA requests by fax, phone, or online (Fax 1‑877‑243‑6930; Phone 1‑800‑285‑9426 TTY/TDD 711; MyPrime.com or CoverMyMeds.com) — use these channels to provide required documentation for PA determinations.
Member Services contact for providers and members
For additional assistance with coverage, exceptions, or formulary interpretation contact BCBSNM Member Services at 1‑866‑689‑1523 (TTY/TDD 711) during business hours.
Policy Revision History
Formulary drug list and utilization controls updated and published (drug list date on front cover).
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