CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Step Therapy Programs for Members on the Performance Full Drug List

Describes step therapy programs that may apply to members' prescription drug benefits on the Performance Full Drug List and lists example drugs/categories affected; informs members/providers how to request exception reviews.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyStep Therapy Programs for Members on the Performance Full Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest an exception review by calling the number on the member ID card or asking the prescribing provider to submit via bcbsnm.com/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrug categories listed as examples

examplesindividual drugs named

1phone/contact route

1online provider route

Drugs Potentially Subject to Step Therapy

Drugs potentially subject to step therapy

Step therapy may be required for the following drugs/categories (examples):

Atypical Antipsychotics: Abilify; Clozapine ODT; Clozaril; Cobenfy; Fanapt; Geodon; Invega; Latuda; Lybalvi; Risperdal; Risperidone ODT; Saphris; Secuado; Seroquel; Seroquel XR; Versacloz; Zyprexa; Zyprexa Zydis

These atypical antipsychotics are examples of agents that may be included in a step therapy program.

Depression agents: Auvelity; Bupropion ER 450 mg; Celexa; Citalopram; Cymbalta; Desvenlafaxine ER; Drizalma Sprinkle; Effexor; Effexor XR; Escitalopram; Exxua; Fetzima; Fluoxetine 60 mg; Lexapro; Paxil; Paxil CR; Pexeva; Pristiq; Prozac; Remeron; Remeron SolTab; Sertraline; Trintellix; Venlafaxine ER; Viibryd; Wellbutrin SR

Examples of antidepressant agents that may be subject to step therapy.

Gabapentin ER: Gralise (gabapentin); Horizant

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyStep Therapy Programs for Members on the Performance Full Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest an exception review by calling the number on the member ID card or asking the prescribing provider to submit via bcbsnm.com/provider.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Step Therapy Program Rules

Step therapy applies to	Examples of drugs/categories	Exception review / how to request
Members on the Performance Full Drug List may be required to follow step therapy programs for specified drug categories and agents.
Atypical antipsychotics; Depression agents (multiple SSRIs/SNRIs/others); Gabapentin ER (Gralise, Horizant); Insomnia agents (Ambien, Lunesta, Quviviq, Rozerem, Silenor, Zolpidem); Kerendia; Topical NSAIDs (Flector, Pennsaid/diclofenac 2% solution)
If a drug is not on the Drug List, the member or prescribing provider can request an exception review. To start the review, call the number on the member ID card or have the provider visit bcbsnm.com/provider. Exception approval may require meeting the step therapy program criteria.

How Providers and Members Request Exceptions and What Triggers Denial

Prior Authorization

How to request an exception or prior authorization

Who may request an exception / prior authorization: Members or their prescribing providers may request an exception review or prior authorization when a prescribed drug is subject to the plan's step therapy program or is not listed on the Drug List.

Requests may be initiated by the member or the prescribing provider
Providers can submit requests online at bcbsnm.com/provider
Members may call the phone number on their Member ID card for assistance

Step Therapy

Step therapy applies to listed drugs

Step therapy applies to listed drugs and categories. Members may be required to try specified preferred or first-line medications (step therapy) for drugs and drug categories included on the Performance Full Drug List before coverage is approved for non-preferred agents.

Examples of affected categories: Atypical Antipsychotics, Depression agents, Gabapentin ER, Insomnia agents, Topical NSAIDs, Kerendia
Step therapy programs are subject to change and additional drugs may be added

Documentation Required

Exception review documentation

Documentation required for exception review: Providers may need to submit clinical documentation demonstrating why the member cannot use the required step therapy medication(s) or otherwise meets exception criteria. Meeting the step therapy program criteria may be required before approval.

Provide clinical rationale and relevant medical records when requesting an exception
Follow submission routes: provider online portal or member phone number on ID card

Denial Risk

What may trigger a denial

Denial triggers: An exception request may be denied if the prescription does not meet the plan's step therapy criteria or required documentation is not provided.

If the member has not tried the required first-line/preferred medication(s) and no medical justification is provided, the exception may be denied
Incomplete or missing clinical documentation can result in denial

Key Definitions

inv-08: Definition of Step therapy

DefinitionStep therapy is a utilization management program in which members are typically required to try specified preferred or first‑line medications (steps) before coverage is provided for other agents listed on the Performance Full Drug List.

ScopeApplies to example drug categories and specific medications included on the Performance Full Drug List; programs and included drugs are subject to change.

Member/Provider actionIf a member’s drug is not on the Drug List, the member or prescribing provider can request an exception review.

inv-09: Definition of Exception review

DefinitionAn exception review is a request by a member or the prescribing health care provider to consider coverage of a drug despite applicable step therapy requirements.

Documentation/criteriaAs part of the exception review, the member may need to meet the drug’s step therapy program criteria before the request will be approved.

How to initiateTo start the review, call the number on the Member ID card or have the prescribing provider visit bcbsnm.com/provider.

OpenPayer

Step Therapy Programs for Members on the Performance Full Drug List

Drugs Potentially Subject to Step Therapy

Step Therapy Program Rules

How Providers and Members Request Exceptions and What Triggers Denial

Key Definitions

Background on Step Therapy