CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Step Therapy Programs for Members on the Balanced Biosimilar Drug List

Defines step therapy programs that may apply to members for specific prescription drug categories and lists example drugs; affects Blue Cross Blue Shield - New Mexico members and their prescribing providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyStep Therapy Programs for Members on the Balanced Biosimilar Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTo request an exception review, call the number on the member ID card or have the prescribing provider start the review at bcbsnm.com/provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplecategories listed

exampleslist is illustrative

yesexception review available

Provider actions and requirements

Step Therapy

Step therapy requirement overview

Step therapy programs may require patients to try and fail preferred or earlier-line therapies before coverage is approved for certain medications. Affected drug categories may change over time; examples include atypical antipsychotics, antidepressants, gabapentin formulations, insomnia agents, topical NSAIDs, and others on the Balanced Biosimilar Drug List. If you are unsure whether a medication is subject to step therapy, call the number on the member's ID card or consult bcbsnm.com/provider.

Examples of affected categories: atypical antipsychotics; depression/antidepressants; gabapentin ER/Horizant; insomnia agents; topical NSAIDs; others on the Balanced Biosimilar Drug List

Prior Authorization

Exception review / prior authorization pathway

Members or prescribers may request an exception (prior authorization) if step therapy requirements cannot be met. To initiate an exception review, call the member services number on the member's ID card or have the prescriber submit a request via the provider resources at bcbsnm.com/provider. Provider-initiated requests should include the clinical rationale for the exception. Timelines for review follow standard prior authorization procedures; contact the phone number on the member ID for specific turnaround expectations.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyStep Therapy Programs for Members on the Balanced Biosimilar Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTo request an exception review, call the number on the member ID card or have the prescribing provider start the review at 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.

Member or provider may call the number on the member ID card to start review
Providers can submit requests or supporting documentation via bcbsnm.com/provider

Documentation Required

Documentation for exception review

Providers should be prepared to submit clinical documentation to support an exception request. Documentation may include the member's prior medication history, reason(s) why preferred/earlier-line therapies are unsuitable (e.g., intolerance, contraindication, lack of efficacy), relevant clinical notes, laboratory results, and any other information that demonstrates medical necessity.

Prior medication history showing trials and outcomes
Clinical rationale for why preferred therapies are inappropriate (adverse reactions, contraindications, lack of efficacy)
Relevant clinical notes and test results

Denial Risk

Denial risk for unmet step therapy

Requests that do not meet the step therapy criteria or that lack sufficient supporting documentation may be denied. Ensure that exception requests clearly document why step therapy cannot be followed and include all requested clinical information to reduce the risk of denial.

Denials may occur if step therapy criteria are unmet or documentation is incomplete
Provide complete clinical justification to minimize denial risk

Step therapy program details

Program / Drug Category	Example prescription drugs (illustrative)	Step therapy requirement	Exception review / prior authorization pathway
Atypical antipsychotics	Abilify; Clozaril; Cobenfy; Fanapt; Geodon; Invega; Latuda; Opipza; Risperdal; Risperidone ODT; Saphris; Secuado; Seroquel; Seroquel XR; Versacloz; Zyprexa; Zyprexa Zydis	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.
Depression medications	Bupropion ER 450 mg; Celexa (citalopram); Cymbalta; Desvenlafaxine ER; Effexor; Effexor XR; Escitalopram (Lexapro); Exxua; Fetzima; Lexapro; Paxil; Paxil CR; Pexeva; Pristiq; Prozac; Remeron; Remeron SolTab; Sertraline; Trintellix; Venlafaxine ER	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.
Gabapentin ER	Gralise; Horizant	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.
Insomnia medications	Ambien; Ambien CR; Lunesta; Rozerem; Belsomra; Dayvigo; Quviviq; Silenor; Zolpidem	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.
Topical NSAIDs	Flector; Licart; Pennsaid (diclofenac 2% solution)	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.
Kerendia (listed as category/drug example)	Kerendia	Member may need to try preferred or earlier-line agents per the plan's step therapy program before coverage of other drugs is approved.	Request an exception review by calling the number on the member ID card or ask the provider to visit bcbsnm.com/provider.

Background and scope

This document is administrative and provides examples of medication categories and specific drugs that may be subject to step therapy under the Balanced Biosimilar Drug List. The listings are illustrative and the program is subject to change; additional drugs may be added to the categories shown. Members and prescribing providers may request an exception review if a drug is not on the Drug List or to seek coverage despite step therapy requirements.