A system error resulted in some Blue Cross and Blue Shield of New Mexico members, with Prime Therapeutics as their pharmacy benefit manager, receiving paid claims without following the necessary prior authorization steps. The error has been fixed. Affected members may now need prior authorization approval for continued coverage of their drug.
Impacted PA programs
The PA programs are:
- Acute Migraine
- GLP-1 Agonists
- Topiramate ER
- Winlevi
Letters are being sent to members whose benefits require them to go through the PA process.
Next Steps
Please submit the PA request for your patient. Visit the Prior Authorization/Step Therapy Programs section for both forms and more information. The prior authorization program encourages safe, cost-effective medication use by allowing coverage when certain conditions are met. A clinical team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA by reviewing U.S. Food and Drug Administration approved labeling, scientific literature, and nationally recognized guidelines.
Important Reminders
If your patients have any questions about their pharmacy benefits, please have them call the number on their member ID card. Members may also visit our member site and log in to Blue Access for Members or MyPrime.com for a variety of online resources.
As a reminder, treatment decisions are always between you and your patients. Coverage is subject to the terms and limits of your patients’ benefit plans.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSNM contracts with Prime 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. MyPrime.com is an online resource offered by Prime Therapeutics.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.
Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSNM ID card.