CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Programs for Members on the Performance Full Drug List

Defines the categories and specific prescription drugs subject to prior authorization under the Performance Full Drug List for Blue Cross Blue Shield - New Mexico members. Affects providers prescribing medications included in the listed categories and members whose benefit plan uses this drug list.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Programs for Members on the Performance Full Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs listed on the Performance Full Drug List according to their category before prescribing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+example drugs and categories listed

Multiplecategories with specialty and non-specialty prior authorization

State-specificapplies to New Mexico membership

Coverage Criteria Overview

This document provides an examples list of drug categories and specific medications associated with Blue Cross Blue Shield — New Mexico’s Performance Full Drug List. It is intended to illustrate agents that may be subject to prior authorization under the listed category programs rather than to state exhaustive clinical criteria. If a member’s drug is not shown on the Drug List, the member or the prescribing health care provider may request an exception review; as part of that review the requestor may need to meet the drug’s prior authorization program criteria before coverage consideration.

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Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Drugs listed on the Performance Full Drug List are subject to category-based prior authorization. Prior authorization must be obtained before dispensing when a drug is included in a listed category or program. Failure to obtain required prior authorization may result in non-coverage or claim denial.

Applies to drugs on the Performance Full Drug List across Non‑Specialty and Specialty prior authorization programs
If unsure whether a drug is on the list, contact the number on the member ID card

Step Therapy

Therapeutic Alternatives and Potential Step Therapy

When requesting prior authorization, prescribers should consider therapeutic alternatives and any step-therapy requirements specified for the drug category. The plan may require trials of preferred or lower-cost alternatives (including formulary agents) before approving a requested medication.

Therapeutic alternatives and step-therapy requirements vary by drug category and are enforced as part of the prior authorization review
Document prior trials, dates, doses, and clinical response to alternatives when submitting a request

Documentation Required

Exception Review and Documentation

Providers or members may request an exception review if the prescribed drug is not covered or if prior authorization criteria are not met. Exception requests must include supporting clinical documentation demonstrating medical necessity and why alternatives are not appropriate.

Include relevant medical records, prior medication trials, laboratory results, and rationale for the exception
Exception review may still require meeting the drug's prior authorization program criteria as part of adjudication
Contact the number on the member ID card for submission instructions and timelines

Documentation Required

Documentation and Recordkeeping

Providers must ensure documentation is complete and retained in the patient record. Incomplete or missing documentation can result in delayed review or denial. Keep a copy of prior authorization approvals and any exception determinations for audit purposes.

Document patient diagnosis, previous therapies and outcomes, proposed treatment plan, and expected length of therapy
Retain prior authorization approval reference numbers and dates in the medical record

Step Therapy and Therapeutic Alternatives

Category / Example Listed Agent(s)	Therapeutic Alternatives (listed)	Supplemental Therapeutic Alternatives (listed)	Coverage implication
Repatha	Rytary (listed under Therapeutic Alternatives in same area of list)		Therapeutic alternatives are listed and may be required or considered prior to authorization of the listed agent
Fintepla / Furoscix (appears together in list)	Absorical, Absorica LD, Adapalene (named among Therapeutic Alternatives in same list segment)	Daraprim (named as a Supplemental Therapeutic Alternative)	Supplemental therapeutic alternatives are identified and may be considered before approving the listed drug
Multiple topical, oral and specialty agents (examples shown across the list)	Examples include Kitabis Pak, Ketoprofen ER, Lidoderm, Qudexy XR, Trokendi XR (therapeutic alternatives appear within list segments)	Examples include topical Doxepin, Zonalon cream, Synera (listed as supplemental alternatives in segments)	Where therapeutic or supplemental therapeutic alternatives are listed, they imply step therapy or consideration of alternatives prior to coverage of the named agent

Key Definitions

Performance Full Drug List

DefinitionPerformance Full Drug List: a payer-maintained list of drug categories and specific medications for which prior authorization programs may apply; third-party brand names are for example only.

ScopeIncludes specialty and non-specialty prescription drugs organized by category; examples shown are illustrative and additional drugs may be added.

Prior authorization requirementDrugs listed under each category on the Performance Full Drug List are subject to prior authorization according to their category/program; failure to obtain required prior authorization may result in denial of coverage.

Exception reviewIf a drug is not on the Drug List, the member or prescribing provider may request an exception review; as part of that review the request may need to meet the drug's prior authorization program criteria.

UpdatesPrograms are subject to change from time to time and additional drugs may be added to the categories listed.

Background

This document is an administrative listing that identifies drug categories and example brand-name agents for which prior authorization programs may apply under the payer’s prescription drug benefit. It is intended for use by providers and plan administrators to understand which product categories commonly require authorization and how to initiate review when a listed medication — or an unlisted medication for a covered member — may need coverage approval. Third-party brand names are provided for example only and the programs may be updated over time.