2026 Drug List (pharmacy formulary) — Coverage Criteria
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This document is the 2026 Drug List (pharmacy formulary) from Blue Cross and Blue Shield of New Mexico describing covered drugs, tiers, specialty drug handling, and processes (prior authorization, step therapy, dispensing limits, exceptions) for members and providers.
No material clinical or coverage changes in this revision.
Formulary Coverage & Conditions
Product listing with associated requirements
Coverage entries listed with qualifications; products are covered per their drug tier but may require authorization or have limits as shown.
No further decision tree present in excerpt
See per-line entries for exact QL values and SP/PA flags
General coverage condition
Covered when prescription meets payer-defined utilization requirements
Examples: obtain PA when 'PA' specified; do not exceed QL; dispense via SP when 'SP' specified
Formulary entries with utilization controls
Coverage and utilization rules as listed for specific products (excerpt):
Based on formulary line
Based on formulary line
Based on formulary line
Based on formulary line
Based on formulary line
Based on formulary line
Based on formulary line
Formulary coverage with utilization management
Coverage stance is indicated per drug line and is subject to indicated requirements/limits.
No patient-specific clinical criteria provided in these chunks.
Formulary listing — coverage entries
Drugs listed with Drug Tier and Requirements/Limits govern coverage and utilization controls.
No additional clinical criteria provided in this segment.
Formulary coverage annotations
Coverage status varies by product and is expressed via Drug Tier and Requirements/Limits flags.
These annotations dictate coverage controls per product in the formulary listing.
Product-level utilization controls
Coverage and utilization controls are applied at the product level as listed below; provider must meet specified control to obtain coverage.
See product entries in chunks 216-235 for specific values
Coverage conditional on PA/QL/SP/ST
Coverage for the listed outpatient drugs is conditional and follows the stated utilization management flags per product (examples below).
Applies product-by-product as listed
Drugs that are not listed on this formulary are generally not covered by the pharmacy benefit; examples called out in the document include non–FDA‑approved products, repackaged medications and some compounded preparations. Coverage may also be limited for products indicated for cosmetic use (for example, hair‑growth agents) or for members outside an approved age range. When a line item includes a utilization control such as PA (prior authorization), coverage requires approval before the medication will be paid; lack of required PA may result in a claim denial. Refer to the member’s benefit materials or the phone number on the ID card for plan‑specific exceptions and to request an exception.
Several formulary entries in this excerpt show an empty Requirements/Limits field. An absence of listed PA/QL/SP/ST on a drug line in this window indicates there are no special utilization controls documented here and the product is presented as standard formulary coverage subject to the member’s plan terms and tier placement.
Within the provided excerpt there are no discrete exclusion rules tied to specific clinical conditions — the content is an itemized formulary listing showing Drug Tier and any Requirements/Limits per product. Where exclusions exist they are described elsewhere; this fragment contains product lines with PA/QL/SP annotations but no standalone exclusion clauses.
No explicit clinical‑exclusion statements (for example, ‘not covered for diagnosis X’) are included in the excerpted lines. The listing focuses on product, tier and utilization controls (e.g., PA, QL, SP, AC), not clinical exclusion criteria.
This window of the formulary does not include specific conditional exclusions tied to patient characteristics or diagnoses. Entries are presented as drug lines with tier assignment and any associated Requirements/Limits rather than as exclusion policies.
No explicit exclusion language appears in the segments cited; instead, product coverage is expressed through Drug Tier assignment and utilization controls. Providers should follow the Requirements/Limits listed per product to determine coverage applicability.
The excerpted text does not state specific exclusions; it lists medications with Drug Tier and Requirements/Limits (for example, quantity limits or prior authorization). Absence of an explicit exclusion in these lines means coverage considerations are determined by the line‑level annotations and the member’s benefit plan.
No clinical exclusions are explicitly stated in this segment. Several analgesic and specialty lines include PA and QL annotations (e.g., QL for opioid patches, sodium oxybate) but the document does not present exclusion rules tied to clinical diagnoses in these chunks.
In the provided excerpt there are no explicit ‘Not Medically Necessary’ declarations for specific therapies. The policy does note that some product categories (for example, cosmetic indications or OTC equivalents) may not be covered and that coverage determinations follow FDA labeling, evidence‑based guidance and benefit plan terms.
The document highlights that products used for cosmetic purposes are commonly excluded from coverage. It also states some medications may be limited by age for safety or cosmetic reasons. Where a product is excluded for cosmetic use this will be reflected in plan materials or the formulary coverage rules.
Across the excerpt there are no explicit ‘Not Medically Necessary’ statements attached to individual line items. The formulary instead uses tiering and utilization controls; absence of an NMN statement in these chunks means no such determination is declared here.
The excerpt does not include explicit ‘not medically necessary’ language. Individual contraceptive and metabolic therapy lines show AC or PA and QL annotations, but no NMN findings are presented in these chunks.
No explicit ‘Not Medically Necessary’ statements appear in these sections. Coverage determinations for the listed products depend on meeting any stated utilization controls and the member’s plan terms rather than on NMN declarations in this excerpt.
The provided lines do not contain NMN determinations. They document product tiers and controls such as PA, QL, and SP, which govern coverage and potential denial risks if not satisfied.
No explicit ‘Not Medically Necessary’ language is present in the cited excerpt. The policy notes that non‑FDA‑approved, repackaged or OTC‑equivalent products may not be covered and that cosmetic uses are commonly excluded — these are programmatic exclusions rather than NMN statements tied to specific clinical scenarios in the excerpt.
There are no explicit NMN statements in these product lines. Vaccine and contraceptive rows show AC or blank Requirements/Limits entries; absence of NMN language here indicates no NMN determinations are provided in this portion of the formulary.
This excerpt does not list specific ‘Not Medically Necessary’ conditions for the products shown. Coverage is controlled by tier assignment and any per‑product utilization requirements noted in the Requirements/Limits field.
Drug Listings & Coding Indicators
Authorization, Documentation & Denial Risk
Prior Authorization Required
Prior Authorization (PA) may be required for many medications listed in this document. When PA applies it will be indicated in the medication entry (Special Requirements column) with a 'PA' flag. Some plans may require PA for additional drugs not shown here; always verify member-specific benefits before dispensing.
- PA flag shown next to affected medications in the formulary
- PA may be required in addition to other controls (QL, SP, ST)
Prior Authorization Required for Select Products
PA is required for many specialty and oncology oral agents, hepatitis C antivirals, vaccines (when noted), CFTR modulators, biologics and other specialty injectables. Example products noted in the formulary that require PA include EPCLUSA, SOVALDI, TRIKAFTA, many cancer oral therapies (ALK, RET, TRK inhibitors), and selected hepatitis C agents.
- Selected hepatitis C antivirals (e.g., EPCLUSA, SOVALDI) = PA, QL, SP
- Many specialty/oncology oral agents listed with PA + QL + SP (examples in formulary)
Prior Authorization Required Where Listed
Where the formulary indicates 'PA' or lists PA in the Requirements/Limits column, providers must obtain authorization before the drug will be covered. PA requirements may be combined with Quantity Limits (QL), Specialty Pharmacy (SP) designation, or Step Therapy (ST).
- PA + QL + SP combinations are common for specialty agents (e.g., OMVOH, TREMFYA, SKYRIZI)
- Failure to obtain PA may result in claim denial or member financial liability
PA Required for Listed Specialty Agents
Many listed specialty agents require prior authorization and are designated for specialty pharmacy (SP). Examples include GENOTROPIN, GALAFOLD, OMNITROPE, and other high-cost biologic or infusible therapies.
- GENOTROPIN – Requirements/Limits = PA, SP
- GALAFOLD – Requirements/Limits = PA, QL, SP
- OMNITROPE – Requirements/Limits = PA, SP
PA Required for Many Specialty Drugs
Numerous specialty drugs across therapeutic areas are subject to PA; these entries frequently also include QL and SP flags. Providers should anticipate PA for pulmonary arterial hypertension agents, biologics, CFTR modulators, and many oncology and rare-disease therapies.
- PA, QL, SP appear together for many specialty agents (e.g., TYVASO, ALYFTREK, TRIKAFTA)
- PA expected for high-cost chronic therapies and rare disease products
PA Required for Many Specialty Agents (Pulmonary & Biologics)
Prior authorization is required for selected pulmonary, respiratory, and biologic specialty agents. Examples include ORENITRAM, TYVASO, XOLAIR, and ALYFTREK — check each formulary line for PA, QL and SP annotations.
- ORENITRAM – Requirements/Limits = PA, QL, SP
- TYVASO and starter kits – PA, QL, SP
- XOLAIR – Requirements/Limits = PA, SP
PA Required for Specific Products
Certain specific products listed require PA and have explicit quantity limits and specialty designations. Examples include OMVOH, SKYRIZI, TREMFYA, and other high-cost injectables shown with PA, QL and SP annotations.
- OMVOH – PA, QL (2 pens/28 days), SP
- SKYRIZI – PA, QL (1 cartridge/56 days), SP
- TREMFYA – PA, QL (1 syringe/28 days), SP
Coverage and Prior Authorization Triggers
Coverage and prior authorization triggers: drugs not listed as covered by your plan or lacking required PA/step therapy/quantity-limit compliance may be denied. Plans may also exclude drugs (e.g., non–FDA approved, repackaged, or OTC-equivalent products). Verify member-specific benefits and follow the formulary flags.
- Non–FDA approved drugs, repackaged medications, and excluded categories may not be covered
- If PA/ST/QL requirements are not met, coverage may be denied and member may be liable
PA and Limits May Trigger Denial
Failure to follow PA, QL, ST or SP requirements can lead to claim denial or member financial responsibility. Prior authorization and dispensing limits are enforceable; some state laws may further restrict coverage for controlled substances dispensed beyond limits.
- Noncompliance with PA/QL/ST may result in denial
- Dispensed quantity beyond QL may be excluded from coverage and billed to member
PA Required for Selected Hepatitis C Agents
Prior authorization is commonly required for newer hepatitis C agents and combination regimens. Examples in the formulary include EPCLUSA, SOVALDI and other sofosbuvir-containing products — these entries are noted with PA, QL and SP where applicable.
- EPCLUSA – Requirements/Limits = PA, QL (28 tablets/28 days), SP
- SOVALDI – Requirements/Limits = PA, QL (30 tablets/30 days), SP
Authorization Required for Many Vaccines
Authorization is required for many vaccines and preventive products when indicated by the formulary (AC or PA flags). Check the vaccine entries (e.g., ACTHIB, AREXVY, seasonal influenza formulations) for Authorization (AC) or PA requirements.
- AC indicates administrative coverage/authorization for vaccines
- Some vaccine formulations list AC in Requirements/Limits
Prior Authorization / Administrative Criteria Required
When a formulary line includes 'PA' or other administrative criteria, providers must follow the listed authorization process and submit required documentation. For exception or expedited reviews follow BCBSNM procedures; exception requests and responses have defined timelines.
- Exception requests: standard response within 3 business days; expedited within 24 hours if life/health threatened
- Contact number on member ID card for PA or exception submissions
PA and QL Entries for Specialty Drugs
Formulary PA entries frequently appear alongside QL (quantity limits) and SP (specialty pharmacy) flags for specialty drugs. Providers should confirm whether an agent requires specialty pharmacy dispensing and adhere to the stated QL.
- PA + QL + SP are combined controls for many agents (examples throughout the formulary)
- Specialty agents often have per‑period quantity limits that must be observed
Required Documentation for PA/SP Drugs
Required documentation: when PA or SP is indicated, providers must supply clinical documentation supporting medical necessity (diagnosis, prior therapies tried, lab results, dosing plan). Specialty products in particular require thorough documentation at submission.
- Provide clinical rationale, prior-treatment history, and relevant labs/imaging as applicable
- Specialty pharmacy submissions may require additional forms or manufacturer support documentation
Follow Requirements / Limits
Follow requirements and limits exactly: prescriptions must match the formulary QL and any PA instructions. If the prescribed quantity exceeds the formulary QL, the extra amount may be non‑covered and billed to the member unless an approved exception exists.
- Match dispensed quantity to formulary QL
- Request exception or prior authorization if a larger quantity is clinically required
Prior Authorization Documentation & Clinical Details
Prior authorization documentation expectations: include drug name, dosage, diagnosis, prior treatment(s) and outcomes, anticipated duration, and any specialty‑pharmacy enrollment details. For CFTR and specialty respiratory agents include genotype, weight/age, and prior CF‑directed therapies where required.
- CFTR/respiratory agents (e.g., TRIKAFTA, KALYDECO) often require genotype and prior therapy documentation
- Quantity limits and refill schedules must be documented for chronic specialty therapies
Match Prescription Quantity to Formulary QL
Match prescription quantity to the formulary QL and the approved PA. Examples: many biologics and specialty injectables specify induction and maintenance quantities (e.g., TREMFYA induction/maintenance packs). Dispense strictly within those limits unless PA/exception authorizes otherwise.
- TREMFYA – induction and maintenance QL specified (induction packs and maintenance pens)
- OMVOH, SKYRIZI, TREMFYA examples show induction/maintenance QLs
Documentation Expectations for PA/SP Drugs
Documentation for PA/SP drugs must be maintained and submitted with the authorization request. Specialty products typically require more extensive documentation and may require ongoing documentation at reauthorization intervals.
- Ongoing reauthorization may require updated clinical data
- Keep records of prior authorizations and approvals for claims and refills
Specialty Products Require Documentation
Specialty products require documentation at initial authorization and often at renewal. Be prepared to provide therapy plans, monitoring schedules, and evidence of benefit for continuation approvals.
- Many specialty agents list PA and SP with QL and require periodic review
- Reauthorization timelines vary by product and clinical program
Documentation and Limits for PA/QL/SP Items
Documentation and limits for PA/QL/SP items: follow the exact formulary annotations for each line item — PA, QL and SP are enforceable controls. For high-cost, rare-disease, or weight‑management agents (e.g., WEGOVY, SAXENDA, MOUNJARO) expect PA plus QL and possible SP handling.
- MOUNJARO – Requirements/Limits = PA, QL (4 pens/28 days)
- WEGOVY – Requirements/Limits = PA, QL (8 pens/180 days)
- SAXENDA – Requirements/Limits = PA, QL (15 mls/30 days)
Required Claim Documentation Aligns with QL and SP
Required claim documentation must align with the approved PA and the formulary QL/SP designation. Submit authorization identifiers and supporting clinical records as required to avoid claim denials or delays.
- Include PA approval number on claims where applicable
- Ensure claim quantities and NDCs match the authorized product and QL
Step Therapy Requirement
Step Therapy (ST) requirements apply where indicated — the formulary will flag medications with 'ST' when a preferred first‑line agent must be tried prior to coverage of the listed drug. Providers may submit a step therapy exception with clinical justification if the preferred agent is unsuitable.
- ST flags are shown in the Special Requirements column when applicable
- Submit ST exception requests with clinical rationale and prior drug history
Dispensing Channel & Administration
Office/hospital-administered meds billed to medical benefit, not pharmacy
Medications administered by a health care professional are covered under the medical benefit, not the pharmacy benefit; do not submit these as pharmacy claims when administration occurs in-office or outpatient settings.
- If medication is administered by a professional (office/hospital outpatient), route the claim to the medical benefit.
Dispense SP-designated products via specialty pharmacy
Follow specialty pharmacy (SP) designation where listed — products marked 'SP' must be dispensed via specialty pharmacy channels and often require PA and SP-specific handling.
- SP designation applies to many parenteral and high-cost agents (e.g., KESIMPTA — PA, QL, SP).
Specialty pharmacy required where 'SP' indicated
Specialty pharmacy is required for many products marked 'SP'; coordinate ordering and claims through the specialty pharmacy per the drug line to meet plan requirements.
- Examples: SKYTROFA, OMNITROPE, many biologics carry SP designations.
SP-designated products require specialty pharmacy handling
Products marked 'SP' are managed through specialty pharmacy channels; providers should use the specialty pharmacy for dispensing and follow PA and documentation procedures tied to SP items.
- SP-designated products frequently include PA and QL requirements in their listing.
Follow SP/site-of-care routing for parenteral and specialty agents
For infusion, infusion center administration, or outpatient specialty therapies, follow the SP designation and site-of-care guidance — many parenteral/specialty agents are managed via specialty pharmacy or medical benefit channels.
- Specialty Pharmacy (SP) designation applies for many parenteral and specialty agents; dispensing should follow SP channel or medical benefit when administered by a health professional.
Specified Quantity Limits (QL) by Product
Key Terms & Abbreviations
Step Therapy Indicators & Expectations
| Indicator | Meaning |
|---|---|
| ST | Denotes drugs commonly requiring step therapy on the drug list; listed when a preferred first‑line medication must be tried prior to coverage of the indicated drug |
| Examples | If a step therapy is commonly required it is noted with 'ST' under Special Requirements; prescriber may request a step therapy exception if preferred agent is not appropriate |
| Observation | Source detail |
|---|---|
| Some products include QL or PA flags | Multiple formulary entries show 'QL' (quantity limits) and 'PA' (prior authorization) in Requirements/Limits, e.g., azithromycin (QL), ARIKAYCE (QL/PA), EPCLUSA (PA) |
| No explicit step therapy steps in excerpt | The listing shows PA/QL entries but does not provide multi‑step sequences or required first‑line agent names in these chunks |
| Observation | Source detail |
|---|---|
| Some products marked SP (specialty) requiring PA | Many specialty agents include 'SP' and 'PA' in Requirements/Limits (examples: oncology and CFTR modulators), but no explicit step sequence provided |
| Examples of SP/PA lines | Entries such as ORENITRAM, TYVASO, ALYFTREK, KALYDECO show 'PA' and 'SP' designations and quantity limits |
| Observation | Source detail |
|---|---|
| AC indicated for many contraceptives | Contraceptive product lines list 'Requirements/Limits = AC' (administrative coverage) and often QL (e.g., 28 tablets/21 days) where applicable |
| AC used as administrative/coverage step | AC appears in Special Requirements for contraceptives and denotes administrative coverage or criteria; may function as a step/authorization code |
| Product | Requirement |
|---|---|
| MOUNJARO (tirzepatide auto‑injector) | Requirements/Limits = PA, QL (4 pens/28 days or 4 pens/180 days depending on strength) — prior authorization required before coverage |
| Product | Annotation |
|---|---|
| KERENDIA (finerenone) | Requirements/Limits = QL (30 tablets/30 days), ST — marked 'ST' indicating step therapy may apply |
| Observation | Source detail |
|---|---|
| Multiple products annotated 'ST' | Formulary lines include 'ST' for selected agents and formulations (examples in chunks: psychiatric agents, KERENDIA; lipid agents have PA/QL but ST not specified) |
| Category | Controls noted |
|---|---|
| New lipid‑lowering agents (examples) | NEXLETOL / NEXLIZET show PA and QL (30 tablets/30 days); step therapy details are not specified in this segment |
| Step | Instruction |
|---|---|
| Step 1 | (No specific Step 1 instructions provided in the excerpt; step therapy is referenced generally and marked with 'ST' where applicable) |
| Summary | Implication |
|---|---|
| No explicit step therapy sequences documented | The excerpt primarily uses PA, QL, and SP flags to control use; formal multi‑step sequences or required prior agents are not listed |
| Scope | Examples |
|---|---|
| Step Therapy applied to selected psychiatric agents | Several antidepressant/antipsychotic entries are annotated 'ST' (examples: AUVELITY, TRINTELLIX, CLOZAPINE ODT, FANAPT titration packs show 'ST') |
| Observation | Source detail |
|---|---|
| Some products/formulations annotated 'ST' | Psychiatric agents (AUVELITY, TRINTELLIX), clozapine ODT, FANAPT titration packs, and GRALISE entries include 'ST' indicating step therapy must be followed where noted |
| Requirement | Provider action |
|---|---|
| Document prior steps as required | When 'ST' is indicated, prior steps should be documented per the step therapy program; prescriber can submit an exception request if preferred agent is inappropriate |
Policy Background & Scope
Specialty drugs in this formulary are high‑cost oral, topical or injectable medications used to treat complex conditions (for example, hepatitis, hemophilia, multiple sclerosis and rheumatoid arthritis). Many specialty agents are managed through a specialty pharmacy channel and may require prior authorization (PA), quantity limits (QL) and specialty pharmacy dispensing (SP); provider‑administered medications may instead be covered under the medical benefit rather than the pharmacy benefit.
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