Drug Coverage — Frequently Asked Questions
The BCBSNM Drug List is a list of approved drugs that are available to Blue Cross Community Centennial members. In most cases only the drugs on the list are covered. A prescription drug list is sometimes called a formulary. BCBSNM and the Prime Therapeutics National Pharmacy and Therapeutics (P&T) Committee meet to review and update the list. This committee has pharmacists and doctors who look at new and existing drugs. They evaluate drugs based for benefit, safety, and cost before including them on the list. Your doctor should consult our Drug List for Blue Cross Community Centennial when prescribing drugs for you.
Usually only drugs on the Drug List are covered. However, if you or your doctor have questions about a drug not on the Drug List, call the BCBSNM Medicaid Pharmacy Department.
Specialty pharmacy drugs are used to treat serious and/or chronic conditions. Examples of serious conditions are:
- multiple sclerosis
- rheumatoid arthritis
Specialty drugs are often injectable. These drugs can be administered by a patient or family member. You must use a contracted specialty network pharmacy to fill these prescriptions. The BCBSNM Medicaid Pharmacy Department will help your doctor coordinate specialty drug benefits for you.
A generic drug is a version of a brand drug. According to the U.S. Food and Drug Administration (FDA), compared to the brand drug, a generic:
- is chemically the same
- works the same in the body
- is just as safe and effective
- often costs much less
OTC medicines are drugs that can be sold without a prescription. Please note: BCBSNM will pay for some OTC drugs for Blue Cross Community Centennial members only, as long as they have their doctor write a prescription for the OTC drug. Some examples of OTC medicines are:
- Pain medicine – such as acetaminophen, naproxen, and ibuprofen
- Heartburn medicine – such as antacids, cimetidine, and ranitidine
- Triple antibiotic ointment – such as neomycin/polymycin B/bacitracin
Blue Cross Community Centennial members must have a prescription from their doctor to get any approved OTC drug.
Certain drugs require approval from BCBSNM. This approval is called "preauthorization." If approval is not obtained, BCBSNM will not pay for them. The list of drugs that require approval is in the Drug List. To request approval, your doctor must call the BCBSNM Medicaid Pharmacy Department at 855-699-0040.
Some drugs have limits to how many tablets or how much liquid can be filled in a month. This is based on the drug maker's research and FDA approval. If your doctor thinks you need more of a drug, he/she can call the BCBSNM Medicaid Pharmacy Department.
BCBSNM asks members to use approved generic drugs to treat medical conditions before we cover a brand drug for the same treatment. Some brand drugs require prior approval if a generic is not used first. Ask your doctor if a generic can be used before he or she prescribes a brand drug that requires step therapy.
- Bring a list of all the drugs that you currently take.
- Let your doctor know if you've had an allergic reaction to any drug.
- Write down questions that you want to ask about your drugs.
- Always follow your doctor's orders for taking your drugs.
Talk with your doctor if you have questions or concerns about drugs you are taking. Your doctor can let you know if a drug on our Drug List is right for you. If you have any questions about prescription drug plan benefits, call Customer Service at 866-689-1523.