Pharmacy Programs

The Prior Authorization and Step Therapy programs encourage safe, cost-effective medication use. Either program may be part of your prescription-drug benefits. Your benefit materials will indicate if it includes Prior Authorization or Step Therapy, as well as which medications are part of your plan.

Prior Authorization

This program requires your doctor to request pre-approval, or prior authorization, for you to get benefits for select medications.

• Your prescription-drug benefits have drug categories and examples of medications that may require prior authorization.
• Some of those drug categories and specific medications are listed below. Not all drug categories are included in your benefit plan. Additional drug categories may be added throughout the year.
  • Prior Authorization Program for Members on a “Metallic” Health Plan
  • Prior Authorization Program for Members on the Basic or Enhanced Drug Lists
  • Prior Authorization Program for Members on the Balanced Drug List
  • Prior Authorization Program for Members on the Performance Drug List
  • Prior Authorization Program for Members on the Performance Select Drug List

• Your doctor can find request forms at bcbsnm.com/provider.
• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Review the member flier for more information about Prior Authorization.
• Call the number on your member card with questions about a specific medication.
   

Step Therapy

This program encourages members to use a “preferred” medication before your benefit plan will cover a “non-preferred” medication. The preferred medication is as safe, works well in treating a specific medical condition and is a cost-effective treatment option. A non-preferred medication could be a costlier prescription. However, if you have prescription history of a “preferred” medication, then your benefit plan will cover a “non-preferred” medication.

Step 1: If possible, your doctor should prescribe a preferred medication that is right for your condition.

Step 2: If you and your doctor decide that a preferred medication is not right for you, or is not effective in treating your condition, your doctor should request a step-therapy exception to cover the non-preferred medication. Your doctor can find request forms at bcbsnm.com/provider.

• The U.S. Food and Drug Administration approves the “first use” of a medication, but those medications may be prescribed for other conditions and would still be included in the Step Therapy program.
• The drug categories and specific medications listed below are only examples. Other medications may be included in your benefit plan’s Step Therapy program. 
  • Step Therapy Programs for Members on a "Metallic" Health Plan
  • Step Therapy Programs for Members on the Basic or Enhanced Drug Lists
  • Step Therapy Programs for Members on the Balanced Drug List
  • Step Therapy Programs for Members on the Performance Drug List
  • Step Therapy Programs for Members on the Performance Select Drug List 

• Not all drug categories are included in all benefit plans.
• As always, cost is only one factor in choosing medication. Treatment decisions are between you and your doctor.
• Review the member flier for more information about Step Therapy.

If you have questions about either the prior authorization or the step therapy programs, call the number listed on your member card.

Specialty medications are those used to treat serious or chronic conditions. Examples include hepatitis C, hemophilia, cancer, multiple sclerosis and rheumatoid arthritis. They often call for carefully following a treatment plan (or taking on a strict schedule), have special handling or storage needs, and may only be stocked by select pharmacies. More information is available in the specialty pharmacy program member flier.

Download the Specialty Pharmacy Program Drug List,  which includes a reminder about coverage for self-administered specialty medications.

A split fill program may apply to some medications like select oral oncology (cancer), multiple sclerosis and iron toxicity drugs. This program lets you try the medication first to make sure you can tolerate any potential side effects. You will get a partial fill of your prescription and only pay for what was filled (a prorated cost of your benefits).

Coverage benefits and requirements may vary based on your plan benefits. Call the number listed on your BCBSNM member ID card if you have any questions.

To order through Accredo:

• For new prescriptions — Ask your doctor to call in your prescription to 1-833-721-1619 or e-prescribe your prescription to Accredo. Your doctor can find e-prescribing information on their website.
• For existing prescriptions — You can request a transfer of your existing prescription for a specialty drug by calling 1-833-721-1619.

A patient care advocate will work with you and your doctor to confirm your order, mailing address and arrange delivery of your covered medications.

When you purchase specialty drugs through Accredo, you can have your self-administered specialty medications delivered directly to you, or to your doctor's office. You also receive at no additional charge:

• One-on-one support and counseling from 500+ condition-specific pharmacists and 600+ nurses
• Simple communication, including refill reminders, by your choice of phone, email, text or web
• An online member website and mobile app to help you manage your prescriptions
• 24/7/365 support and free standard shipping

BCBSNM members who use oral oncology or hemophilia specialty drugs may have other in-network specialty pharmacy options. Log in to your Blue Access for Members^SM  account to find a preferred specialty pharmacy near you.

Accredo is a specialty pharmacy that is contracted to provide services to members of Blue Cross and Blue Shield of New Mexico (BCBSNM). The relationship between Accredo and BCBSNM is that of independent contractors. Accredo is a trademark of Express Scripts Strategic Development, Inc.

Prime Therapeutics LLC is a pharmacy benefit management company, contracted by BCBSNM to provide pharmacy benefit management and related other services. BCBSNM, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.

Express Scripts® Pharmacy, the mail order pharmacy for members with BCBSNM prescription drug coverage, provides safe, fast and cost-effective pharmacy services that can save you time and money. With this program, you can obtain up to a 90-day supply of long-term (or maintenance) medications through Express Scripts® Pharmacy. Maintenance medications are those drugs you may take on an ongoing basis to treat conditions such as high cholesterol, high blood pressure or diabetes. Download the maintenance drug list to check if your medication is included.

Ordering Through Express Scripts^® Pharmacy

Getting Started Online

You have more than one option to fill or refill a prescription online or from a mobile device:

• Visit express-scripts.com/rx. Follow the instructions to register and create a profile.
• Log in to myprime.com  and follow the links to Express Scripts® Pharmacy.
   

Order Over the Phone

Call 1-833-715-0942, 24/7, to refill, transfer a current prescription or get started with home delivery. Please have your member ID card, prescription information and your doctor’s contact information available.

Through the Mail

To send a prescription order through the mail, log in to Blue Access for Members^SM. Complete the mail order form. Mail your prescription, completed order form and payment to Express Scripts® Pharmacy.

For more information about using mail order, you can download the Express Scripts^® Pharmacy flier.

If you have coverage through Blue Cross and Blue Shield of New Mexico, vaccinations may be covered under the medical benefit or the prescription drug benefit, based on your plan. Select vaccines can be conveniently administered at a pharmacy near you. These vaccines can help protect you from illnesses such as the flu, pneumonia, shingles, hepatitis B, meningitis, HPV, tetanus, diphtheria and pertussis.

To learn more about which vaccines are available under your plan for you and your covered family members, check your benefit materials for details and any necessary copays. Or, you can call the phone number listed on your member ID card.

• For vaccinations covered under the prescription drug benefit, select vaccines can be conveniently administered at a participating vaccine network pharmacy near you. Just hand your member ID card to the pharmacist.
• To see a complete list of all participating pharmacies, search the pharmacy network on myprime.com and filter for vaccine pharmacies. 
• Before you go, be sure to confirm the location's participation and hours, vaccine availability and ask about any other age limits, restrictions or requirements that may apply.

More information is available in the pharmacy vaccine program member flier.

If you have BCBSNM prescription drug benefit coverage, you have access to our team of clinical pharmacists and other resource tools to help answer questions you may have about your prescriptions.

The Pharmaceutical Care Management (PCM) program helps you get the best results from the medicines you take. A member of the PCM team may reach out to talk with you about the medicines you take. The medication review by a clinical pharmacist helps make sure the medicines you are taking are safe and work well. The pharmacist can also share ways to help you lower your out-of-pocket costs for your prescriptions.

For more information about how PCM works:

• Download the PCM Program member flier.