CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Blue Cross and Blue Shield of New Mexico Drug List Formulary — Coverage Criteria

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Defines the drug formulary for BCBSNM members, including coverage rules, restrictions (prior authorization, quantity limits, step therapy), specialty pharmacy requirements, and member/provider instructions for exceptions and access. Applies to members of Blue Cross and Blue Shield of New Mexico plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyBlue Cross and Blue Shield of New Mexico Drug List Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization for medications marked 'PA' and ensure specialty drugs are filled by an in-network specialty supplier.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA presentDrugs requiring prior authorization

QL presentDrugs with quantity limits

ST presentDrugs subject to step therapy

ME90Morphine equivalent limit

~150Approx. drug entries shown

14–15 daysSpecialty split-fill initial supply

Formulary Coverage Rules

General formulary coverage

Covered when ALL of the following are met

Formulary coverage prerequisites: Member has a medical need for the drug; medication is filled at an in‑network pharmacy; member complies with BCBSNM eligibility and other plan rules.

Based on general formulary guidance.

Administration and supplier requirements: Specialty drugs must be filled by a participating in‑network specialty drug supplier (Accredo preferred) when the product is designated SP.

Specialty drugs require prior authorization before a prescription may be filled and may be subject to limited distribution supplier requirements.

Utilization management adherence: Prescriptions are subject to applicable utilization controls listed on the drug line (Prior Authorization (PA), Quantity Limits (QL), Age Limits (AL), Step Therapy (ST), Split Fill (SF), and morphine‑equivalent monitoring ME90) and those controls must be satisfied for coverage.

Failure to obtain required PA or to meet QL/ST may result in non‑coverage.

Coverage with product-specific PA/QL/age limits

Covered with utilization management controls as listed per product

Product-level coverage rules: Each drug presentation is covered only if the specific product line requirements are met (e.g., the product's tier assignment and any listed PA, QL, AL, SP, ST or 90‑day mail provisions).

See the individual product entry for exact PA age thresholds and quantity limits.

Age‑based prior authorization: When an age limit is listed (e.g., PA (<=4 yr), PA (<=9 yr), PA (<=11 yr), PA (<=17 yr)), prior authorization must be obtained for members at or below the indicated age for that product to be covered.

Examples of age thresholds appear on antipsychotics and pediatric stimulant entries.

Quantity limits and mail supply: Coverage is subject to the quantity limits shown on the product line (examples: QL (60 tablets/30 days), QL (120 tablets/30 days), QL (480 mls/30 days) or mail 90‑day supply where noted); dispensing beyond the QL requires a documented exception.

QL values and mail day supply ('90') are specified per presentation in the drug list.

The plan excludes specific categories of products from coverage. Not covered are agents for anorexia, weight loss, or weight gain, cosmetic enhancing drugs, fertility drugs, most over‑the‑counter products (unless otherwise listed), surgical supplies/medical devices, and certain cough/cold opioid formulations for patients <18 years. The plan also excludes Drug Efficacy Study Implementation (DESI) items (drugs not shown to be safe and effective), as well as experimental and investigational therapies.

No additional explicit exclusions for individual drugs are captured in this extract. The absence of a specific product on the exclusion list in these chunks means no exclusion was recorded in this portion of the document; consult the full formulary for product‑level exclusion determinations.

Drugs described as experimental and investigational and items designated under DESI (Drug Efficacy Study Implementation) — i.e., drugs not shown to be safe and effective — are not covered by the plan.

Within the chunks provided there are no explicit statements labeling any listed product as not medically necessary. No 'not medically necessary' determinations are shown in this extract.

Formulary Codes, Limits and Key Metrics

Formulary action codesmixed

PA	Prior Authorization — identified in drug list when required
QL	Quantity Limit — identified in drug list when present
ST	Step Therapy — identified in drug list when applicable
ME	Morphine Equivalent indicator — used to identify opioids with ME dosing limits
SF	Split Fill — specialty drugs subject to Specialty Pharmacy Split Fill Program

NDC / package descriptors as listed (product strengths/forms)mixed

ADEMPAS - riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (90 tablets/30 days), SP
ORENITRAM - treprostinil diolamine tab er 0.125 mg, 0.25 mg, 1 mg, 2.5 mg	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (300 tablets/30 days), SP
TYVASO - treprostinil inhalation solution 0.6 mg/ml	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (81.2 mls/28 days), SP

Formulary drug presentationsmixed

N/A - drug presentations listed

Multiple NDC-level drug presentations and strengths are listed (e.g., risperidone tabs 0.25–4 mg; risperidone solution 1 mg/ml; asenapine patch strengths; UZEDY risperidone SC prefilled syringes).

No billing codes in this extractmixed

No codes listed

Morphine Equivalent daily limit — ME90 90 mg/day

ME90 limitMorphine Equivalent daily limit set at 90 mg per day (ME90).

Applies toOpioid and opioid-containing products identified with 'ME90' in drug list entries.

Related requirementsPrescriptions subject to ME90 may also carry PA and QL flags; exceeding ME90 may trigger denial or additional review.

Opioid refill threshold — 75% of original fill

Refill thresholdOpioid refill allowed only after 75% of the original fill has been used (refill threshold = 75% of original fill).

Applies toOpioid and opioid-containing products with ME90 designation and related QL entries.

Consequence if unmetRefills requested before meeting the 75% threshold may be denied or require prior authorization.

Specialty split-fill initial supply — 14- or 15-day supply twice a month for first 2-3 months

Initial split-fill supplySpecialty Pharmacy Split Fill Program: first 2–3 months receive a 14- or 15-day supply twice a month.

PurposeTo manage dose titration, reduce waste, and allow monitoring by specialty pharmacists during therapy initiation.

Post-stabilizationAfter dose stabilization (typically after 2–3 months), member may receive a full one-month supply.

QL examples — examples like 90 tablets/30 days; 81.2 mls/28 days

Tablet exampleQL example: 90 tablets per 30 days (e.g., many chronic oral meds).

Oral solution exampleQL example: 81.2 mls per 28 days (TYVASO inhalation solution).

Large-volume liquid exampleQL example: 2700 mls per 30 days for certain acetaminophen/codeine liquids noted elsewhere in list.

Age-based PA thresholds — pediatric PA examples

Pediatric PA examplesAge-based PA thresholds shown (examples): risperidone formulations PA (<=4 yr); thiothixene PA (<=11 yr); ziprasidone PA (<=9 yr); many ADHD stimulants PA (<=5 yr).

Narcotic products in minorsSome narcotic-containing products require PA for minors (e.g., acetaminophen w/ codeine PA (<=17 yr)).

ActionProviders must check PA and AL flags on individual drug lines when prescribing for pediatric patients.

Quantity limits / mail supply — QL and mail 90-day examples

Mail-order 90-day supply'90' denotes availability of up to a 90-day supply via mail order for applicable products.

Common QL formatsExamples include QL (30/30 days), QL (60/30 days), and QL for injectables expressed per 28 days or per kit (vials/28 days).

Specialty injectablesInjectable therapies often have QL expressed as vials or syringes per 28 or 30 days (e.g., REPATHA, AVONEX).

Quantity Limits examples — assorted QL examples

Assorted tablet/capsule QLsExamples in the formulary: QL 30 tablets/30 days (efavirenz-lamivudine-tenofovir), QL 60 tablets/30 days (some statins or ertugliflozin strengths).

High-count QLsExamples include QL 300 tablets/30 days (certain PAH therapies) and QL 360 tablets/30 days (acarbose 25 mg).

Injectable/pen QLsExamples include QL 2 syringes/28 days or QL 6 pens/28 days for biologic injectables (REPATHA, adalimumab biosimilars).

Provider Requirements and Authorization Process

Prior Authorization

Prior authorization required for PA‑listed medications

Certain medications (including specialty drugs) require prior authorization before they may be filled; these are identified by a 'PA' in the drug list and specialty drugs require PA and must be filled by a participating specialty supplier (Accredo preferred).

Medications requiring PA are marked 'PA' in the 'Necessary actions, restrictions, or limits on use' column.
Specialty drugs require prior authorization and must be dispensed by an in‑network specialty supplier; Accredo is the preferred supplier.

Note

Check drug list for 'PA' flag before prescribing

Verify whether a drug line carries a 'PA' flag by checking the formulary legend and the product's 'Necessary actions, restrictions, or limits on use' column; the legend defines PA as Prior Authorization.

Refer to the legend (PA = Prior Authorization) and each drug's entry to confirm whether PA applies.

Prior Authorization

PA applies when 'PA' is indicated on the drug line

If a formulary entry shows 'PA' in the 'Necessary actions, restrictions, or limits on use' column, prior authorization must be obtained before the prescription will be covered.

PA is indicated by the 'PA' abbreviation in product entries; coverage may be denied without PA.

Prior Authorization

Secure PA for select branded and specialty agents

Obtain prior authorization for identified brand and specialty products that list PA in their entry (examples in this extract include liraglutide/Victoza (DX, PA, QL), Omnitrope (PA, SP), and ACTHAR (PA, SP)).

Liraglutide (Victoza) — DX, PA, QL noted.
Omnitrope — PA, SP noted.
ACTHAR — PA, SP noted.

Prior Authorization

PA required for listed PA products (examples)

Prescribers must request prior authorization for drugs explicitly labeled with 'PA' before coverage is granted — for example, ORILISSA, sapropterin (Kuvan), tolvaptan, REPATHA and ENTRESTO are designated PA in their product lines.

ORILISSA (elagolix) — Necessary actions = PA, QL.
Sapropterin (Kuvan) — Necessary actions = PA, SF, SP.
REPATHA (evolocumab) — Necessary actions = PA, QL.

Prior Authorization

PA plus QL/SP often required for PAH and specialty agents

Many pulmonary arterial hypertension (PAH) agents and other specialty products are marked PA and also carry quantity limits and specialty (SP) distribution requirements; obtain PA and arrange specialty supply as required.

ADEMPAS, Letairis, Tracleer, ORENITRAM and TYVASO entries include PA, QL and SP designations.
ORENITRAM and TYVASO show PA with QL and SP handling.

Prior Authorization

PA (including age‑based) required for select CNS agents

Prior authorization is required for multiple central nervous system products and may include pediatric age thresholds — for example, risperidone formulations are listed with PA for ages <=4 years.

Risperidone tabs, solution and ODT entries indicate PA (<=4 yr) and specific QL values.

Prior Authorization

PA required for certain narcotic products in minors

Obtain prior authorization for narcotic‑containing products when PA and age limits apply; for example, acetaminophen with codeine solution is listed with PA for patients <=17 years and ME90 limits.

Acetaminophen with codeine solution — ME90, PA (<=17 yr), QL (2700 mls/30 days).
Tramadol entries also list ME90 and PA (<=17 yr) where shown.

Prior Authorization

PA required for migraine biologics (AIMOVIG, AJOVY, EMGALITY)

Prior authorization is required for selected migraine biologics (AIMOVIG, AJOVY, EMGALITY); these entries list PA and specific quantity limits (e.g., AIMOVIG QL 1 syringe/28 days).

AIMOVIG — PA, QL (1 syringe/28 days).
AJOVY — PA, QL (3 syringes/84 days).
EMGALITY — PA, QL (1 syringe/28 days or other listed pack limits).

Prior Authorization

PA required for numerous specialty injectables and hematology products

Many specialty injectables, coagulation factors, growth factors and C1 esterase inhibitors require prior authorization and are often designated SP; request PA and coordinate specialty dispensing prior to therapy.

ADVATE, ADYNOVATE, ALPHANATE and other hemophilia products — PA, SP.
ARANESP and other growth factors — PA, SP.
HAEGARDA, icatibant (Firazyr) — PA and QL noted.

Prior Authorization

Age‑limited PA applies to select pediatric liquids/formulations

Some pediatric oral liquids and formulations carry age‑based PA or age limits; check the product entry for AL/PA designations (examples include potassium chloride and rivaroxaban suspension age thresholds in the full list).

TolVaptan and other pediatric‑sensitive products list PA and AL where applicable.
Rivaroxaban suspension and select oral liquids include age‑based PA/AL annotations elsewhere in the formulary.

Step Therapy

Step therapy — try preferred agents first

Step therapy requires trying preferred formulary drugs before coverage of an alternative agent; products subject to step therapy are identified by 'ST' in the drug list and exceptions can be requested.

ST appears in the 'Necessary actions, restrictions, or limits on use' column to indicate step therapy.
If step therapy is required, an exception request may be submitted via Member Services.

Note

Verify 'ST' flag on formulary entries

Confirm whether step therapy applies by checking for the 'ST' flag in the formulary legend and on individual product entries; ST is defined as Step Therapy in the legend.

Legend defines ST = Step Therapy; verify the ST flag on the drug line to determine applicability.

Step Therapy

ST present indicates potential step therapy requirement

When the 'ST' abbreviation appears on a prescription product entry, step therapy requirements may apply and the provider should follow the formulary's step sequence or request an exception.

ST on the product line signals step therapy may be required; specific step sequences are in product‑level rules (when provided).

Step Therapy

ST required for certain antidiabetic branded agents (examples)

Step therapy is required for multiple DPP‑4 and SGLT2 branded agents where 'ST' is listed — for example, alogliptin products and Steglatro (ertugliflozin) entries show ST and associated quantity limits.

Alogliptin and combination products — Necessary actions include QL and ST.
Steglatro (ertugliflozin) 5 mg and 15 mg — QL and ST noted.

Note

ST indicated in legend (specific rules not in extract)

The formulary legend includes 'ST' as a step therapy indicator, but specific step sequences or prior step agents are not detailed in this excerpt; check full product rules or contact Member Services for step details.

ST is defined in the legend, yet product‑specific step instructions may be outside this extract.

Note

Step therapy flag present — verify product details

The document uses 'ST' as a step therapy flag in the legend; this extract contains few explicit step assignments — verify product pages for explicit step requirements before prescribing.

Formulary shows ST in legend but product‑level step details may be elsewhere in the full formulary.

Note

ST referenced — confirm specific product requirements

Step therapy is referenced in the legend and may apply to entries, but many specific step requirements are not present in these chunks; providers should confirm product‑level ST rules or seek exceptions if needed.

ST is noted in multiple sections of the formulary; review the complete product entry for exact step criteria.

Note

ST flag present — product sequences may be elsewhere

The 'ST' flag is used throughout the formulary as an administrative restriction, though specific step sequences are absent in this extract; confirm step therapy sequences from full formulary resources prior to initiating therapy.

Legend defines ST = Step Therapy; product step sequences may be detailed on product pages not included here.

Documentation Required

How to request prior authorization (fax / phone / web)

Submit prior authorization (coverage exception) requests using the payer's accepted channels: fax to 1‑877‑243‑6930; phone at 1‑800‑285‑9426 (TTY/TDD 711); or via MyPrime.com or CoverMyMeds.com (online forms).

Fax: 1‑877‑243‑6930.
Phone: 1‑800‑285‑9426 (TTY/TDD: 711).
Web: MyPrime.com or CoverMyMeds.com (coverage exception form).

Documentation Required

Legend flags indicate required documentation/actions

The formulary legend and product entries use administrative flags to indicate required documentation or processing: AL = Age Limit, PA = Prior Authorization, QL = Quantity Limits, ST = Step Therapy, SP = Specialty, DX = Diagnosis Required, SF = Split Fill, ME90 = Morphine Equivalent.

Check product entries for AL, PA, QL, ST, SP, DX, SF, ME90 flags which indicate required administrative steps.
DX requires a diagnosis on the claim or PA documentation when specified.

Documentation Required

Abbreviations denote administrative requirements

The formulary abbreviations define administrative requirements (e.g., PA = Prior Authorization; DX = Diagnosis Required); providers must follow these indicated requirements on the prescription or prior authorization submission.

Abbreviations used in the formulary (PA, DX, QL, SP, ST, AL, ME90, SF) denote administrative controls to be met.

Documentation Required

Include diagnosis on claim or PA for 'DX' products

If a product is designated 'DX', the prescriber must include the diagnosis on the claim or in the prior authorization documentation; 'PA' items require a prior authorization submission before coverage.

DX flagged products require a diagnosis on the claim or within PA documentation.
PA flagged products require a PA request for coverage consideration.

Documentation Required

Annotate prescriptions with required DX or SP status

When prescriptions indicate program status flags (e.g., DX, SP), ensure required annotations are present on the prescription or PA submission; specialty drugs (SP) must be handled per specialty pharmacy procedures.

Prescriptions should show required diagnosis or program status when DX is listed.
SP designation requires specialty pharmacy distribution and related documentation.

Billing Rule

Adhere to product quantity limits (QL) or obtain exception

Apply the stated quantity limits at dispensing and provide documentation or an exception request if dispensing beyond the listed QL (e.g., many products show QL values such as 90 tablets/30 days or 81.2 mls/28 days).

ORENITRAM — QL (300 tablets/30 days).
TYVASO — QL (81.2 mls/28 days).
Many products include QL values that must be adhered to at dispensing.

Documentation Required

Document QL and SP for specialty therapies (MS examples)

For MS and other specialty therapies marked SP, follow documentation for both quantity limits and specialty dispensing (e.g., AVONEX QL 1 kit/28 days, SP); supply and claims must reflect the QL and SP designations.

AVONEX — QL (1 kit/28 days), SP.
MS therapies frequently require specialty channel dispensing and QL compliance.

Billing Rule

Specialty biologics — dispense via SP and follow QL

Specialty biologics are marked SP and include specific quantity limits per 28 days (e.g., adalimumab biosimilars QL 2 syringes/28 days or 2 pens/28 days); dispense via specialty pharmacy and adhere to QL.

Adalimumab biosimilars (ADBM, HADLIMA, SIMLANDI) — QL (2 syringes/28 days or 2 pens/28 days), SP.
Dispense through specialty pharmacy per SP designation.

Documentation Required

Provide clinical documentation to support PA/SP/QL requests

Prescribers must supply clinical documentation to support prior authorization and specialty (SP) requests, and provide justification for quantity requests that exceed the listed QL.

PA and SP designations require supporting clinical documentation with the request.
Requests exceeding QL require medical justification.

Denial Risk

Denial risk if PA/ST/QL requirements unmet

Failure to obtain a required prior authorization, to meet step therapy requirements, or to adhere to quantity or specialty rules may result in the plan denying coverage or not paying for the drug.

Coverage may be denied if PA is not obtained.
Failure to meet ST or QL may lead to non‑coverage.

Note

PA and DX are actionable legend flags — verify per drug

The formulary legend lists administrative action flags such as PA and DX; confirm these flags on each drug entry because they can trigger additional authorization or documentation requirements.

PA and DX are listed in the legend as possible plan action flags; check product lines for these indicators.

Denial Risk

Denial risk for QL/SP/SF noncompliance

Coverage or processing may be denied if prescriptions exceed stated quantity limits, are not dispensed via required specialty channels (SP), or do not follow split‑fill (SF) rules where indicated.

Exceeding QL or failing to use SP channel can result in denial or processing restrictions.
SF (Split Fill) rules apply for some specialty agents during initiation.

Denial Risk

PA‑labeled drugs require authorization or risk denial

Requests for drugs labeled 'PA' will require prior authorization submissions; failure to obtain PA for these products (examples shown throughout the formulary) may lead to denial or non‑coverage.

Products such as ORILISSA, sapropterin (Kuvan), tolvaptan and others list PA and require authorization prior to coverage.

Prior Authorization

PA required for listed PAH drugs (examples)

Prior authorization is specifically required for several PAH agents shown with PA flags (for example, ADEMPAS and certain treprostinil products); submit PA documentation to avoid non‑coverage.

ADEMPAS — PA, QL (90 tablets/30 days), SP.
TREPROSTINIL products (ORENITRAM, TYVASO) — PA with QL and SP noted.

Prior Authorization

Check for age‑based PA thresholds on product lines

Many product entries include age‑based PA limits; check the product line for AL/PA annotations (e.g., risperidone formulations list PA (<=4 yr) in multiple presentations).

Risperidone ODT, solution and tablets show PA for patients <=4 years with specified QL values.

Denial Risk

Observe ME90 limits and PA for opioid products in minors

Opioid and certain narcotic products include ME90 monitoring and age‑based PA in their entries; for example acetaminophen with codeine solutions list ME90 and PA (<=17 yr) — ensure PA and ME90 limits are observed.

Acetaminophen/codeine solutions — ME90 and PA (<=17 yr) with QL.
Other opioid entries list ME90 and may require PA for minors.

Denial Risk

PA/SP/QL designations can trigger extra processing or denial

Drugs with 'PA' or 'SP' designations — and those with QL — can trigger additional processing steps or denials if requirements are not met; verify PA/SP/QL before dispensing to avoid coverage issues.

Many hemophilia and biologic products are PA and SP and require adherence to QL to prevent denial.
PA and SP status may require specialty pharmacy coordination and prior approval.

Note

Key Terms and Legend

Generic drug — definition from document

Generic drug definitionA generic drug is FDA-approved as having the same active ingredient as the brand-name drug and often costs less.

Identification in listGeneric drugs are listed in lower-case italics in the formulary; brand names are capitalized.

Tier implicationsTier assignment (1 = generic, 2 = brand) is shown in the drug list legend and entries.

Specialty drug — definition and handling requirements

Specialty drug definitionSpecialty drugs treat complex, chronic conditions and often require special handling, administration, and prior authorization; they must be filled by an in-network specialty supplier (Accredo preferred).

Dispensing limitsSpecialty drugs can be filled for up to a 30-day supply and may be subject to split-fill during initial therapy (14–15 day supplies twice monthly for 2–3 months).

Specialty channelMany specialty drugs are designated 'SP' in the formulary and require specialty pharmacy distribution; limited distribution vendors may be used when necessary.

Quantity Limits — QL abbreviation

QL abbreviationQL = Quantity Limits (maximum allowed quantity per specified period, shown on drug lines).

UsageQL entries commonly show units per 30 days, 28 days, or per year depending on product type.

Relation to coverageDispensing beyond QL may require a quantity limit exception or prior authorization and can trigger denial if unmet.

Age Limit — AL abbreviation

AL abbreviationAL = Age Limit (age-based prior authorization thresholds or limits indicated on drug lines).

ExamplesUsed to indicate pediatric age thresholds for PA (e.g., PA (<=4 yr) for risperidone).

Action for providersProviders should verify age limits on product entries and include age information in PA requests when applicable.

Prior Authorization — PA abbreviation

PA abbreviationPA = Prior Authorization — approval required from BCBSNM before certain medications may be filled.

How to requestProviders may submit PA requests via phone, fax, MyPrime.com, or CoverMyMeds.com as noted in policy documentation guidance.

ConsequenceFailure to obtain PA when required may result in non-coverage or claim denial.

Formulary abbreviations — QL, SP, SF, PA, DX, ST, AL explained

Formulary abbreviations setQL = Quantity Limits; SP = Specialty; SF = Split Fill; PA = Prior Authorization; DX = Diagnosis Required; ST = Step Therapy; AL = Age Limit; ME90 = Morphine Equivalent; 90 = 90 days at mail.

Legend usageThese abbreviations appear in the formulary legend and on individual product lines to indicate administrative controls.

Provider actionCheck drug-line flags for these abbreviations to determine required documentation or prior approval steps.

PA — Prior Authorization

PA — shorthandPA denotes Prior Authorization is required for the drug; listed in legend and on product entries.

EffectPrescriptions marked PA require an approved exception before coverage; contact Member Services for submission instructions.

Associated flagsPA often appears with QL, AL, or SP on drug lines indicating combined controls.

QL — Quantity Limits

QL — shorthandQL denotes Quantity Limits — maximum quantity allowed over a specified period (e.g., per 30 days).

ExamplesCommon formats include QL (30 tablets/30 days), QL (2 syringes/28 days), or annual vial limits for injectables.

EnforcementDispensing beyond QL may need an exception and can lead to denial if not authorized.

ST — Step Therapy

ST — shorthandST denotes Step Therapy — members must try specified preferred drugs before alternatives are covered.

DetectionST appears in the formulary legend and on product lines where step therapy applies.

Provider guidanceIf ST is listed, providers may request an exception if the preferred drug is contraindicated or not tolerated.

SP — Specialty

SP — shorthandSP denotes Specialty — drugs requiring specialty pharmacy handling and distribution (often marked with QL and PA).

RequirementsSpecialty drugs must be filled by a participating specialty supplier (Accredo preferred) and may have SP-specific QL and split-fill rules.

ExamplesMany biologics and complex injectables are flagged SP in the formulary (e.g., adalimumab biosimilars).

DX — Diagnosis Required

DX — shorthandDX denotes 'Diagnosis Required' — a diagnosis must be present on the claim or PA documentation when DX is listed.

Provider actionInclude the required diagnosis on the prescription claim or PA submission for DX-designated products.

Effect on coverageFailure to include diagnosis when DX is required may result in denial or processing delay.

90 — 90 days available at mail order

90 — mail order supply'90' indicates that a 90-day supply is available via mail order for applicable products.

Where shownThe '90' notation appears in the legend and on product lines eligible for mail-order 90-day dispensing.

ImplicationProducts marked '90' may be dispensed in larger quantities through the mail channel per plan rules.

Legend codes — document legend defining abbreviations used

Legend overviewDocument legend defines codes used throughout the formulary (e.g., 1 = Generic, 2 = Brand, PA = Prior Authorization, QL = Quantity Limits, SP = Specialty, SF = Split Fill, ST = Step Therapy, DX = Diagnosis Required, 90 = 90 days mail, AL = Age Limit, ME90 = Morphine Equivalent).

PurposeLegend codes provide at-a-glance administrative controls applicable to each drug line.

Provider useAlways consult the legend when interpreting product-level flags and requirements.

Legend abbreviations — codes like 1=generic, 2=brand, PA, QL

Legend abbreviations listKey legend items: 1 = Generic Drugs; 2 = Brand Drugs; 90 = 90 days available at mail order; PA = Prior Authorization; QL = Quantity Limits; SP = Specialty; ST = Step Therapy; DX = Diagnosis Required; SF = Split Fill; AL = Age Limit; ME90 = Morphine Equivalent.

Where displayedShown in the header/legend sections and repeated throughout product listings for clarity.

Clinical implicationThese abbreviations trigger specific administrative actions (PA requests, QL enforcement, age checks, etc.).

PA — Prior Authorization

PA (alternate)PA indicates Prior Authorization is required before coverage; listed as PA in legend and product entries.

ActionProviders should submit PA requests per the plan's procedures; lack of PA can result in non-coverage.

Relation to other flagsPA often co-occurs with AL, QL, SP, or DX on drug entries indicating combined restrictions.

QL — Quantity Limits

QL (alternate)QL denotes Quantity Limits — specified per product (e.g., tablets/30 days, mls/30 days, syringes/28 days).

EnforcementDispensing beyond the stated QL may require documentation or an exception request.

Legend presenceQL is defined in the legend and appears on many product lines across the formulary.

SP — Specialty (duplicate/alternate chunk)

SP (alternate)SP indicates Specialty — products requiring specialty pharmacy distribution and handling.

RequirementsSpecialty designation often means PA, QL, and SP channel requirements apply; Accredo is the preferred specialty supplier.

ExamplesMany biologics and complex injectables are flagged SP (e.g., adalimumab biosimilars).

ME90 — Morphine Equivalent metric (definition)

ME90 definitionME90 = Morphine Equivalent — used to indicate morphine-equivalent oversight or limits applied to opioid products in the formulary.

UsageME90 appears in the legend and on opioid product lines to denote morphine-equivalent monitoring/limits.

Associated controlsProducts with ME90 may also carry QL and PA flags; see individual entries for exact QL values.

ME90 — Morphine Equivalent monitoring/limit (alternate)

ME90 monitoringME90 is used as a monitoring/limit indicator for opioid products; entries with ME90 may have specified QL and PA requirements.

ExamplesMany opioid and opioid-containing products listed across the formulary include ME90 with associated QL (e.g., hydrocodone, codeine formulations).

ImplicationExceeding ME90 thresholds can trigger prior authorization review or denial of coverage.

QL — Quantity Limits (definition/alternate)

QL (definition alternate)Quantity Limits restrict the amount of a drug covered over a specified time period (e.g., per 30 days or per 28 days).

NotationShown as QL on product lines and defined in the legend.

Provider actionRequests exceeding QL typically require an exception or prior authorization and supporting documentation.

PA — Prior Authorization (additional duplicate chunk)

SF — Split FillSF denotes Split Fill — specialty drugs labeled 'SF' fall under the Specialty Pharmacy Split Fill Program for initial therapy.

Program detailInitial split-fill dispensing provides 14–15 day supplies twice monthly for the first 2–3 months to allow dose adjustments and reduce waste.

Post-initial supplyAfter stabilization, standard one-month supplies are permitted.

QL — Quantity Limits (duplicate/alternate chunk)

QL (duplicate)QL indicates Quantity Limits as noted in legend and product listings.

Typical periodsLimits are commonly specified per 30 days, 28 days, or per year depending on the medication form.

ImpactAdherence to QL is required for coverage; exceptions must be requested when clinically necessary.

SP — Specialty (definition/alternate chunk)

SP (duplicate)SP marks Specialty drugs — these require specialty pharmacy handling and prior authorization.

DistributionSpecialty drugs must be dispensed by an in-network specialty supplier (Accredo preferred); limited distribution vendors allowed when necessary.

Associated controlsSP items commonly carry QL and PA flags and may be subject to split-fill under the SF program.

PA — Prior Authorization (additional duplicate chunk)

PA (additional)PA = Prior Authorization; listed in legend and applied to many specialty and select brand products.

Where to findPA appears in the formulary legend and on individual product lines indicating a required prior approval step.

Provider requirementSubmit PA requests per plan instructions; absence of an approved PA may result in non-coverage.

QL — Quantity Limits (additional duplicate chunk)

QL (additional)QL = Quantity Limits, defined in the legend and used throughout product entries to indicate dispensing caps.

Common unitsShown as tablets/30 days, mls/30 days, syringes/28 days, or annual counts for specific therapies.

Exception processProviders may request quantity limit exceptions when medical necessity supports larger quantities.

SP — Specialty (additional duplicate chunk)

SP (additional)SP marks Specialty — specialty therapies often require special handling, PA, and are dispensed via specialty pharmacy channels.

ImplicationSP designation typically accompanies QL and PA requirements on drug entries.

Network supplierAccredo is the preferred specialty supplier for BCBSNM when SP designation applies.

AL — Age Limit (additional duplicate chunk)

AL (additional)AL = Age Limit — indicates age-based restrictions or PA thresholds on product lines.

ExamplesUsed for pediatric PA thresholds shown for antipsychotics and stimulants.

Provider actionConfirm patient age against AL flags before dispensing; include age info in PA when required.

Initial Coverage Controls

Specialty split-fill

Specialty Pharmacy Split Fill Program initial dispensing

Split-fill initial period: For members newly starting specialty therapy, the first 2–3 months are dispensed as split fills: a 14‑ or 15‑day supply twice per month to manage dosing changes and reduce waste.14- or 15-day supply twice a month for first 2-3 months

After dose stabilization, a full one‑month supply may be provided.

Applicability: Any specialty drug labeled 'SF' in the drug list falls under this program; specialty drugs must be dispensed by a participating specialty supplier (Accredo preferred).

Program intended to reduce waste and allow additional specialty pharmacist touchpoints.

Initial therapy controls

Initial coverage requires adherence to listed utilization controls

Prior authorization at initiation: If the product's drug line lists 'PA', prior authorization must be obtained before the initial fill will be covered.

Contact Member Services or submit a PA per payer procedures.

Quantity limits at initiation: Initial fills must not exceed the product's listed quantity limit; early fills or amounts above the QL require prior approval or exception documentation.See product QL (e.g., 60 tablets/30 days)

QL values vary by presentation; refer to the product entry.

Pediatric age limits at initiation: When an age limit (AL) is specified on the product line, coverage for initial therapy requires meeting the age‑based PA or restrictions shown for that product.Examples: PA (<=4 yr), PA (<=5 yr), PA (<=9 yr)

Age thresholds differ by drug class and presentation.

Migraine biologics initiation

Migraine biologic initiation controls

Prior authorization requirement: Prior authorization is required for AIMOVIG (erenumab), AJOVY (fremanezumab) and EMGALITY (galcanezumab) as indicated on their product lines.

PA is listed on each migraine biologic product entry.

Quantity limits for initiation: Coverage is subject to the migraine biologic quantity limits shown: AIMOVIG QL 1 syringe/28 days; AJOVY QL 3 syringes/84 days; EMGALITY QL values shown per presentation (e.g., 1 syringe/28 days or 9 syringes/180 days).AIMOVIG 1 syringe/28 days; AJOVY 3 syringes/84 days; EMGALITY per product line

Prescribers must request exceptions if a different quantity is clinically required.

Step Therapy Requirements

Step therapy rule	Notes
Try preferred formulary drug(s) first before coverage of alternative agent
Medications subject to step therapy are identified by 'ST' in the drug list; failure to try preferred agent(s) may result in non-coverage until step requirement is met

Step therapy application	Source / legend
Step therapy (ST) applied when indicated on formulary entries
'ST' is listed in the formulary legend as the Step Therapy flag; check individual drug lines for ST notation

Product	Formulary controls
Alogliptin (alogliptin; alogliptin/metformin; alogliptin/pioglitazone)
Listed with Quantity Limits (QL) and Step Therapy (ST); examples: QL (30 or 60 tablets/30 days) and ST noted on product lines

Product	Formulary controls
Steglatro (ertugliflozin) 5 mg and 15 mg
Each strength listed with Quantity Limits (60 tablets/30 days for 5 mg; 30 tablets/30 days for 15 mg) and Step Therapy (ST) flag

Legend flag	Details in excerpt
ST (Step Therapy) included in formulary legend
Legend shows ST abbreviation, but specific step sequences or step details are not provided in this extract

ST flag presence	Excerpt specifics
Step Therapy (ST) flag exists in legend and appears across formulary sections
This segment does not list the precise step requirements for flagged products

ST noted	Step details available?
Step therapy is referenced in the legend and applied to some product lines
Specific step sequences or required prior agents are not detailed in these chunks of the extract

Legend includes ST	Information in extract
The legend repeatedly defines ST = Step Therapy
No explicit stepped sequences (e.g., required first-line drug names or timeframes) are provided in this extract

ST usage	Available specifics
ST (Step Therapy) is used for some entries as noted in the legend and product lines
This portion of the document does not list the specific step criteria or sequences for those entries; refer to full formulary product lines for details

Product-Specific Quantity Limits

Various QL examples — e.g., no more than 60 tablets per 30 days

QL example — small tabletsExample: no more than 60 tablets per 30 days (illustrative example shown in general guidance).

QL example — varied formsFormulary contains many specific QL examples across drug classes (tablets, capsules, liquids, syringes).

ActionCheck individual drug lines for exact QL values before dispensing or submitting PA/QL exceptions.

efavirenz-lamivudine-tenofovir df 400-300-300 mg — QL 30

Productefavirenz-lamivudine-tenofovir df 400-300-300 mg

Quantity LimitQL 30 tablets/30 days

Source lineListed in antiretroviral section with QL noted.

emtricitabine caps 200 mg (Emtriva) — QL 30

Productemtricitabine capsules 200 mg (Emtriva)

Quantity LimitQL 30 capsules/30 days

Related entrySoln form has separate QL of 720 mls/30 days.

EMTRIVA - emtricitabine soln 10 mg/ml — QL 720

ProductEMTRIVA - emtricitabine solution 10 mg/ml

Quantity LimitQL 720 mls/30 days

NoteSolution form QL differs from capsule form; check product-specific QL.

ISENTRESS raltegravir chewable 25 mg — QL 180

ProductISENTRESS - raltegravir chewable 25 mg

Quantity LimitQL 180 tablets/30 days

SectionListed in antiretroviral entries with QL specified.

SUNLENCA therapy pack — QL 4

ProductSUNLENCA therapy pack (lenacapavir) 4 x 300 mg

Quantity LimitQL 4 tablets/365 days

Formulation noteTherapy pack presentations have annual QL expressed per 365 days.

CAYSTON aztreonam lysine inhalation — QL 84

ProductCAYSTON - aztreonam lysine inhalation

Quantity LimitQL 84 boxes/56 days

SpecialtyMarked SP where specified.

LAGEVRIO molnupiravir cap 200 mg — QL 40

ProductLAGEVRIO - molnupiravir cap 200 mg

Quantity LimitQL 40 capsules/30 days

TierTier Level = 2 as listed.

Malarone atovaquone-proguanil — QL 30

ProductMalarone (atovaquone-proguanil)

Quantity LimitQL 30 tablets/90 days

IndicationAntimalarial—QL differs by presentation.

Vancomycin hcl cap 125 mg and 250 mg — QL 120

ProductVancomycin hcl capsules 125 mg and 250 mg

Quantity LimitQL 120 capsules/30 days

Form typesCapsule strengths listed separately with same QL.

palbociclib (IBRANCE) — QL 21 tablets

Productpalbociclib (IBRANCE)

Quantity LimitQL 21 tablets/28 days

SpecialtyMarked SP where specified.

taletrectinib (IBTROZI) — QL 90 capsules

Producttaletrectinib (IBTROZI)

Quantity LimitQL 90 capsules/30 days

TierTier Level = 2 as shown.

ponatinib (ICLUSIG) — QL 30 tablets

Productponatinib (ICLUSIG)

Quantity LimitQL 30 tablets/30 days

FlagsSF and SP noted where applicable.

imatinib mesylate (Gleevec) 100 mg — QL 90 tablets

Productimatinib mesylate (Gleevec) 100 mg

Quantity LimitQL 90 tablets/30 days

ChannelSF and SP indicated for select strengths.

imatinib mesylate (Gleevec) 400 mg — QL 60 tablets

Productimatinib mesylate (Gleevec) 400 mg

Quantity LimitQL 60 tablets/30 days

NotesHigher-strength presentation has lower QL per 30 days.

ibrutinib (IMBRUVICA) caps — QL 90 capsules

Productibrutinib (IMBRUVICA) capsules

Quantity LimitQL 90 capsules/30 days

Alternative formOral suspension form has QL 216 mls/30 days.

ibrutinib (IMBRUVICA) oral suspension — QL 216 mls

Productibrutinib (IMBRUVICA) oral suspension

Quantity LimitQL 216 mls/30 days

ChannelSP flagged for specialty handling.

acarbose tab 25 mg (Precose) — QL 360

Productacarbose tablet 25 mg

Quantity LimitQL 360 tablets/30 days

Mail90-day mail option noted for many formulations where applicable.

acarbose tab 50 mg (Precose) — QL 180

Productacarbose tablet 50 mg

Quantity LimitQL 180 tablets/30 days

Formulary noteQL varies by strength; check product line.

acarbose tab 100 mg (Precose) — QL 90

Productacarbose tablet 100 mg

Quantity LimitQL 90 tablets/30 days

Strength-based QLHigher strength often has lower pill-count QL.

BAQSIMI glucagon nasal powder — QL 6 packs

ProductBAQSIMI glucagon nasal powder

Quantity LimitQL 6 packs per year

RelatedOther glucagon products (GVOKE) also have QL 6 units per year.

GVOKE glucagon auto-injectors/kits — QL 6

ProductGVOKE glucagon auto-injectors/kits/pens

Quantity LimitQL 6 pens/kits/syringes per 365 days

Formulary noteAnnual QL applies to these emergency-use products.

Steglatro ertugliflozin 5 mg — QL 60

ProductSteglatro (ertugliflozin) 5 mg

Quantity LimitQL 60 tablets/30 days

ST flagST (step therapy) also applies for some strengths.

Steglatro ertugliflozin 15 mg — QL 30

ProductSteglatro (ertugliflozin) 15 mg

Quantity LimitQL 30 tablets/30 days

NotesDifferent strengths have different QL values.

Rapid-acting insulin products — QL 45 mls

ProductRapid-acting insulin products (Admelog, MeriLog, Novolog variants)

Quantity LimitQL 45 mls/30 days (common for rapid- and short-acting insulins).

Mail option90-day mail noted for many insulin presentations where applicable.

Short-acting insulins — QL 45 mls

ProductShort-acting insulins (Humulin R, Novolin R)

Quantity LimitQL 45 mls/30 days

Formulary placementListed under Diabetes - Insulins with QL and 90-day mail notations.

Octreotide acetate pref syringes — QL 90 syringes

ProductOctreotide acetate prefilled syringes

Quantity LimitQL 90 syringes/30 days

ChannelMarked SP for specialty handling.

Octreotide acetate injection vials — QL 90 vials

ProductOctreotide acetate injection vials (Sandostatin)

Quantity LimitQL 90 vials/30 days

SpecialtySP designation applies for these injectable formulations.

Somavert (pegvisomant) — QL 30 vials

ProductSomavert (pegvisomant)

Quantity LimitQL 30 vials/30 days

ChannelSP indicated for this growth hormone-related injectable.

Tolvaptan (Samsca) 15 mg — QL 30

ProductTolvaptan (Samsca) 15 mg

Quantity LimitQL 30 tablets/365 days for 15 mg strength; QL 60 tablets/365 days for 30 mg strength.

FlagsPA and SP also apply where indicated.

Metformin 500 mg — QL 90 tablets

ProductMetformin 500 mg

Quantity LimitQL 90 tablets/30 days; 90-day mail option noted.

TierTypically Tier 1 (generic) as listed.

Octreotide acetate injection (selected strengths) — QL 90 mls/30 days or 90 vials/30 days

ProductOctreotide acetate injection (selected strengths)

Quantity LimitQL 90 mls/30 days or QL 90 vials/30 days depending on presentation.

SpecialtySP and QL apply as listed.

ORILISSA (elagolix) — QL examples

ProductORILISSA (elagolix) 150 mg and 200 mg

Quantity LimitQL 30 tablets/30 days for 150 mg; QL 60 tablets/30 days for 200 mg; PA required.

NotesPA and QL both apply; check strength-specific QL before dispensing.

SOMAVERT (pegvisomant) — QL 30 vials/30 days

ProductSOMAVERT (pegvisomant)

Quantity LimitQL 30 vials/30 days

SPSpecialty handling indicated.

Tolvaptan (Samsca) — QL examples

ProductTolvaptan (Samsca) 15 mg and 30 mg

Quantity Limit15 mg: QL 30 tablets/365 days; 30 mg: QL 60 tablets/365 days.

FlagsPA and SP apply for these strengths.

REPATHA (evolocumab) — QL 2 syringes/28 days or 6 pens/28 days

ProductREPATHA (evolocumab)

Quantity LimitQL 2 syringes/28 days for syringe; QL 6 pens/28 days for auto-injector; PA required.

ChannelSP and PA commonly accompany biologic QLs.

atorvastatin — QL 30 tablets/30 days

Productatorvastatin

Quantity LimitQL 30 tablets/30 days; 90-day mail option noted.

Formulary noteCommon lipid-lowering agent with standard QL and mail options.

ADEMPAS (riociguat) — QL 90 tablets

ProductADEMPAS (riociguat)

Quantity LimitQL 90 tablets/30 days

FlagsPA and SP noted for PAH agents.

ORENITRAM (treprostinil diolamine) — QL 300 tablets

ProductORENITRAM (treprostinil diolamine)

Quantity LimitQL 300 tablets/30 days

SpecialtySP and PA apply; large QL reflects therapy pack packaging.

TYVASO (treprostinil inhalation solution) — QL 81.2 mls

ProductTYVASO (treprostinil inhalation solution)

Quantity LimitQL 81.2 mls/28 days

FlagsPA and SP typically apply for PAH inhalation therapies.

UPTRAVI (selexipag) — QL 60 tablets

ProductUPTRAVI (selexipag)

Quantity LimitQL 60 tablets/30 days (other pack QLs noted for titration packs).

SpecialtyPA and SP apply; titration packs have separate QL rules.

Epinephrine auto-injector (EpiPen) — QL 4 pens

ProductEpinephrine auto-injector (EpiPen)

Quantity LimitQL 4 pens per prescription

NoteEmergency-use products have QL limits per prescription.

risperidone (various forms) — QL varies by formulation

Risperidone examplesRisperidone formulations have varied QLs: e.g., QL 60 tablets/30 days, QL 120 tablets/30 days, QL 480 mls/30 days for solution, QL 2 vials/28 days for IM ER formulations.

Age-based PAThese risperidone entries also show PA (<=4 yr) age limits where indicated.

Provider actionCheck formulation-specific QL and AL flags before dispensing.

AVONEX — QL 1 kit/28 days

ProductAVONEX (interferon beta-1a)

Quantity LimitQL 1 kit/28 days

SpecialtySP indicated for MS therapies and injectables.

methylphenidate formulations — multiple QLs depending on formulation

Product groupMethylphenidate formulations

Quantity LimitsMultiple QLs depending on formulation (examples include QL 60 capsules/30 days, QL 30 tablets/30 days, QL 360 tablets/30 days).

Age-based PAMany methylphenidate products show PA (<=5 yr) age thresholds.

acetaminophen w/ codeine liquid — QL 2700 mls/30 days and ME90

Productacetaminophen with codeine liquid

Quantity LimitQL 2700 mls/30 days and ME90 designation; PA applies for minors (<=17 yr).

Related entriesOther codeine-containing and butalbital-containing products also list ME90 with pediatric PA thresholds.

acetaminophen-caffeine-dihydrocodeine cap — QL 300

Productacetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg

Quantity LimitQL 300 capsules/30 days

FlagME90 indicated on opioid-containing entries.

acetaminophen w/ codeine soln 120-12 mg/5ml — QL 2700 mls

Productacetaminophen w/ codeine solution 120-12 mg/5ml

Quantity LimitQL 2700 mls/30 days

Associated controlsME90 and pediatric PA (<=17 yr) present for some formulations.

butalbital-acetaminophen-caff w/ codeine cap — QL 180

Productbutalbital-acetaminophen-caffeine with codeine cap 50-325-40-30 mg

Quantity LimitQL 180 capsules/30 days; ME90 and PA (<=17 yr) noted.

ContextPart of several headache and analgesic combination entries with opioid controls.

adalimumab-adbm prefilled syringe kit — QL 2 syringes

Productadalimumab-adbm prefilled syringe kit

Quantity LimitQL 2 syringes/28 days (or 2 pens/28 days); SP.

SpecialtyMarked SP and subject to specialty pharmacy distribution.

AIMOVIG (erenumab) — QL 1 syringe

ProductAIMOVIG (erenumab)

Quantity LimitQL 1 syringe/28 days; PA required.

Mail option90-day mail availability noted for eligible injectables.

CERDELGA (eliglustat) 84 mg — QL 60 capsules

ProductCERDELGA (eliglustat) 84 mg

Quantity LimitQL 60 capsules/30 days; SP where indicated.

NotesListed with specialty handling in formulary.

ELIQUIS (apixaban) — QL varies

ProductELIQUIS (apixaban) various forms

Quantity LimitQL varies by formulation (examples shown include QL 5 boxes/28 days and QL 74 tablets/180 days).

Provider noteCheck specific presentation for exact QL before dispensing.

eltrombopag (Promacta) — QL examples

Producteltrombopag (Promacta)

Quantity LimitQL 30 packets/tablets per 30 days; up to 60 tablets/30 days for higher strengths.

SpecialtySP indicated for certain presentations.

enoxaparin (Lovenox) prefilled syringes — QL 30 syringes/365 days

Productenoxaparin (Lovenox) prefilled syringes

Quantity LimitQL 30 syringes/365 days

ChannelPA and SP may apply for certain dosing regimens.

icatibant (Firazyr) — QL 6 syringes

Producticatibant (Firazyr)

Quantity LimitQL 6 syringes/30 days

SpecialtySP applies for HAE treatments.

HAEGARDA — QL 27 vials/28 days (2000 unit) or 18 vials (3000 unit)

ProductHAEGARDA (C1 esterase inhibitor)

Quantity LimitQL 27 vials/28 days (for 2000 unit) or QL 18 vials/28 days (for 3000 unit); PA and SP noted.

IndicationHereditary angioedema management with specialty channel requirements.

rivaroxaban suspension (Xarelto) — QL 4 bottles

Productrivaroxaban suspension (Xarelto)

Quantity LimitQL 4 bottles/30 days; PA (>=13 yr) may apply.

Formulary noteSuspension presentations have separate QL from tablet forms.

XARELTO 10 mg — QL 39 days/365 days

ProductXARELTO 10 mg

Quantity LimitQL 39 days/365 days (starter/maintenance packaging noted).

Provider noteAnnual-day-count QL used for some formulations.

latanoprost ophth soln (Xalatan) — QL 1 bottle

Productlatanoprost ophthalmic solution (Xalatan)

Quantity LimitQL 1 bottle/30 days

SpecialtyOphthalmic supplies follow bottle-based QLs.

tobramycin ophth soln (Tobrex) — QL 15 mls

Producttobramycin ophthalmic solution (Tobrex) 0.3%

Quantity LimitQL 15 mls/30 days

Formulary noteOphthalmic liquids have small-volume QLs expressed in mls per 30 days.

Specialty Pharmacy and Dispensing Site Requirements

Billing Rule

Specialty drugs must be dispensed by in‑network specialty pharmacy

Specialty drugs must be filled by an in‑network specialty drug supplier; Accredo is identified as the preferred BCBSNM specialty supplier for dispensing SP products.

Specialty drugs require specialty pharmacy dispensing by a participating network supplier.
Accredo is the preferred specialty supplier for BCBSNM.

Billing Rule

SP flag indicates specialty channel for select PAH and specialty products

Many PAH and other specialty products are marked 'SP' indicating specialty distribution is required; follow SP routing for claims and dispensing.

Entries such as ADEMPAS, bosentan, ambrisentan show SP designation alongside PA and QL.

Billing Rule

Injectables with vial/kit QL are usually specialty‑supplied

Injectable disease‑modifying therapies have vial/kit quantity limits and are typically designated SP; coordinate infusion center, home infusion or specialty pharmacy supply per the product's SP/QL entries.

AVONEX and other injectable DMTs — QL per 28 days and SP; arrange specialty distribution.
Many injectables include vial/kit QL and SP handling requirements.

Note

Biosimilar Entries and Notes

Billing Rule

Adalimumab biosimilars — QL 2 syringes/28 days and SP

Select adalimumab products are listed with QL (2 syringes/28 days or 2 pens/28 days) and specialty designation (SP); dispense through specialty pharmacy and process claims to reflect the QL and SP status.

Adalimumab‑ADBM, HADLIMA, SIMLANDI entries each list QL (2 syringes/28 days or 2 pens/28 days) and SP.
Claims should reflect the QL and SP to avoid processing issues.

Billing Rule

Adalimumab presentations require SP dispensing and QL adherence

Alternate adalimumab listings similarly show QL and SP designations — ensure specialty dispensing and quantity adherence for these biosimilar/autoinjector presentations.

HADLIMA and SIMLANDI entries include QL (2 syringes/28 days) and SP for syringe and pen kits.

Billing Rule

Maintain QL and SP handling for adalimumab products

Adalimumab product lines across the formulary consistently include QL and SP flags; follow specialty pharmacy procedures and apply the 2 syringes/28 days or 2 pens/28 days QL when dispensing.

Multiple adalimumab biosimilar entries list the same QL and SP requirements.
Dispense and adjudicate claims to the specified QL to ensure coverage.

Formulary Background

The formulary groups drugs by therapeutic category and applies consistent coverage rules: products are covered when they meet general formulary prerequisites and any product‑level utilization controls. Key controls shown in the drug list include Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), Age Limits (AL), and Specialty (SP) designation. Specialty drugs require PA and must be dispensed through an in‑network specialty supplier (Accredo is the preferred supplier); many specialty items are subject to split‑fill during initial therapy and have specified QL (for example, QL values and 90‑day mail options are shown on product lines).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyBlue Cross and Blue Shield of New Mexico Drug List Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization for medications marked 'PA' and ensure specialty drugs are filled by an in-network specialty supplier.

SourceLink

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Blue Cross and Blue Shield of New Mexico Drug List Formulary — Coverage Criteria

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Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyBlue Cross and Blue Shield of New Mexico Drug List Formulary — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApril 2026

Next Review DateN/A

Key ActionObtain prior authorization for medications marked 'PA' and ensure specialty drugs are filled by an in-network specialty supplier.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA presentDrugs requiring prior authorization

QL presentDrugs with quantity limits

ST presentDrugs subject to step therapy

ME90Morphine equivalent limit

~150Approx. drug entries shown

14–15 daysSpecialty split-fill initial supply

Formulary Coverage Rules

General formulary coverage

Covered when ALL of the following are met

Formulary coverage prerequisites: Member has a medical need for the drug; medication is filled at an in‑network pharmacy; member complies with BCBSNM eligibility and other plan rules.

Based on general formulary guidance.

Administration and supplier requirements: Specialty drugs must be filled by a participating in‑network specialty drug supplier (Accredo preferred) when the product is designated SP.

Specialty drugs require prior authorization before a prescription may be filled and may be subject to limited distribution supplier requirements.

Failure to obtain required PA or to meet QL/ST may result in non‑coverage.

Coverage with product-specific PA/QL/age limits

Covered with utilization management controls as listed per product

See the individual product entry for exact PA age thresholds and quantity limits.

Examples of age thresholds appear on antipsychotics and pediatric stimulant entries.

QL values and mail day supply ('90') are specified per presentation in the drug list.

Within the chunks provided there are no explicit statements labeling any listed product as not medically necessary. No 'not medically necessary' determinations are shown in this extract.

Formulary Codes, Limits and Key Metrics

Formulary action codesmixed

PA	Prior Authorization — identified in drug list when required
QL	Quantity Limit — identified in drug list when present
ST	Step Therapy — identified in drug list when applicable
ME	Morphine Equivalent indicator — used to identify opioids with ME dosing limits
SF	Split Fill — specialty drugs subject to Specialty Pharmacy Split Fill Program

NDC / package descriptors as listed (product strengths/forms)mixed

ADEMPAS - riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (90 tablets/30 days), SP
ORENITRAM - treprostinil diolamine tab er 0.125 mg, 0.25 mg, 1 mg, 2.5 mg	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (300 tablets/30 days), SP
TYVASO - treprostinil inhalation solution 0.6 mg/ml	Tier Level = 2; Necessary actions, restrictions, or limits on use = PA, QL (81.2 mls/28 days), SP