CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Prior Authorization Programs for Members on the Balanced Drug List

This document lists prescription drugs on the Balanced Drug List and indicates which require non-specialty or specialty prior authorization for Blue Cross Blue Shield - New Mexico members. It affects prescribers and pharmacists seeking coverage for listed drugs for BCBSNM members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPrior Authorization Programs for Members on the Balanced Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization or submit an exception request as directed for drugs listed on the Balanced Drug List.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks

Manydrug categories

~100+listed drugs

Empavelirepeated notable drug

Coverage Criteria

No specific exclusion conditions are listed in the available excerpt of this policy. The document functions as an administrative listing mapping drugs and drug categories to the plan’s prior authorization programs (Non‑Specialty or Specialty) rather than enumerating explicit clinical exclusions.

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Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Balanced Drug List items are subject to prior authorization. Drugs and drug categories listed on the Balanced Drug List require the corresponding prior authorization program; coverage may be denied if prior authorization is not obtained.

Examples include many specialty and non-specialty prescription drugs across listed categories (see Balanced Drug List).
Lack of prior authorization for a listed drug may result in denial of coverage.

Step Therapy

Tiered / Grouped Products and Step Therapy

Tiering / Grouped Products and Step Therapy Potential — Some categories on the Balanced Drug List are presented in groups (e.g., Group 1 and Group 2 for GLP‑1 agonists and other therapeutic classes). Grouping implies preferred agents and may indicate a step therapy pathway where preferred (Group 1) products are required before coverage of Group 2 products.

Examples: GLP‑1 Agonists — Group 1 (Bydureon, Byetta, Mounjaro, etc.) vs Group 2 (Ozempic, Rybelsus, Trulicity, etc.).
Grouped listings across the document may reflect preferred alternatives or required trials prior to coverage of non-preferred agents.

Note

How to Request Review

How to Request a Prior Authorization Review — To initiate a review or request an exception for a drug not listed, call the number on the member's ID card or have the prescribing provider submit the request via the BCBSNM provider site.

Call the phone number on the member ID card for member-specific benefits and to begin prior authorization.
Providers may be directed to bcbsnm.com/provider to submit prior authorization or exception requests.

Documentation Required

Documentation and Review Pathway

Documentation and Program Details — Prior authorization programs require supporting clinical documentation and adherence to the program criteria. When requesting review, be prepared to provide medical records, prior therapy history, and any other documentation specified by the program.

Requests for exception reviews may require meeting the drug's prior authorization criteria before approval.
These programs are subject to change; additional drugs may be added to categories over time.

Step Therapy / Tiering

Category	Group 1 (examples)	Group 2 (examples)
{"text":"Combination NSAIDs","status":""},{"text":"Duexis; ibuprofen + famotidine; Vimovo; naproxen + esomeprazole","status":""},{"text":"Yospral (aspirin-omeprazole)","status":""}
{"text":"Continuous Glucose Monitor","status":""},{"text":"Dexcom G6 CGM System; Dexcom G7 CGM System","status":""},{"text":"FreeStyle Libre; FreeStyle Libre 2; FreeStyle Libre 3","status":""}
{"text":"GLP-1 (glucagon-like peptide-1) Agonists","status":""},{"text":"Bydureon BCise; Byetta (exenatide); Liraglutide; Mounjaro","status":""},{"text":"Ozempic; Rybelsus; Trulicity; Victoza","status":""}
{"text":"PCSK9 Inhibitors","status":""},{"text":"Praluent","status":""},{"text":"(no examples listed)","status":""}
{"text":"VMAT2 Inhibitors (formerly Huntington's Disease / Tardive Dyskinesia)","status":""},{"text":"Austedo; Austedo XR","status":""},{"text":"Ingrezza; Xenazine (tetrabenazine)","status":""}
{"text":"Various specialty agents (examples)","status":""},{"text":"Austedo, Vowst, Voxzogo, Voydeya, Vykat XR, Wakix, Xolair, Xolremdi, Yorvipath, Zeposia, Zilbrysq, Zokinvy (where listed as group 1)","status":""},{"text":"Corresponding group 2 entries for many of the above are listed as blank or alternate brands where provided","status":""}

Implied Requirement	What the listing indicates	Provider action
{"text":"Prior authorization required for listed categories","status":""},{"text":"Items shown under categories with '1 =' and '2 =' suggest tiering or preferred versus non-preferred products; specific step sequence rules are not provided in the excerpt","status":""},{"text":"Submit prior authorization per the Balanced Drug List designation or request an exception review; contact number on member ID or bcbsnm.com/provider to start review","status":""}
{"text":"Step therapy may be applied","status":""},{"text":"Group 1 versus Group 2 presentation implies a potential step or preferred-agent requirement (e.g., try Group 1 agents before Group 2)","status":""},{"text":"Follow the payer's prior authorization pathway; if clinical criteria are not met, submit exception with supporting documentation","status":""}
{"text":"Specialty vs Non-specialty PA pathways","status":""},{"text":"Document labels in the full list indicate whether Non‑Specialty Prior Authorization or Specialty Prior Authorization applies to specific drugs (not all examples in excerpt)","status":""},{"text":"Use the appropriate PA route shown on the Balanced Drug List when submitting requests","status":""}

Billing Rule

Action: confirm 1 vs 2 subgroup and follow that pathway

Across the Balanced Drug List many categories use the notation “1 =” and “2 =” to show subgrouping; treat these as actionable tiers—confirm which subgroup the prescribed product belongs to and pursue the corresponding authorization pathway.

Document the product’s subgroup (1 or 2) on authorization requests.
Expect that subgrouping may determine preferred versus alternative products and authorization requirements.

Background

This policy is an administrative mapping of listed prescription drugs and drug categories to the Blue Cross Blue Shield New Mexico prior authorization programs on the Balanced Drug List. It identifies which products are subject to prior authorization pathways and groups some products into tiered subgroups (shown as “1 =” and “2 =”), implying preferred versus non‑preferred or sequential options within a category. The document does not provide clinical indications, dosing rules, or specific step‑therapy requirements in the excerpt; it instructs providers or prescribers to initiate an exception or prior authorization review by calling the number on the member ID card or directing the prescriber to bcbsnm.com/provider.