Blue Cross Blue Shield of New Mexico
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Prescription Drugs

Drug Limitations, Exclusions, and
Prior Authorization Criteria

prescription bottleThe BCBSNM/HMONM Pharmacy Benefit provides coverage of most drugs for our members. Effective communication about specific drug limitations is important for consistent benefit administration and customer satisfaction. The following information includes the drug limitations, exclusions, and prior authorization criteria for most BCBSNM and HMONM pharmacy plans.

I. Drug Limitations:

A1. BCBSNM/HMONM 3-Tier Prescription Drug Plans: 30-day supply or 120 units, whichever is less per copay at retail pharmacies; or 90-day supply or 360 units, whichever is less per two retail copays at mail-order.

A2. BlueChoice Plus 25/50 Percent Prescripton Drug Plan: 30-day supply or up to 180 units, whichever is less per copay at retail pharmacies; or 90-day supply or up to 540 units, whichever is less per two retail copays at mail-order.

B. Drug-specific quantity limits are identified on the Managed Drug Limitations (MDL) list. Requests for larger quantities are referred to the BCBSNM Health Services department for review.

II. Drug Exclusions:

Certain classes of medications may be excluded from the benefit and therefore are not covered. Examples of common exclusions are:

A. Drugs used for smoking cessation (both Legend and OTC)

  1. Zyban
  2. Bantron
  3. Nicorette and Nicorette DS gum
  4. Habitrol patch
  5. Nicoderm patch
  6. Nicotrol patch, inhaler, and spray
  7. Prostep
  8. Wellbutrin (Also used for depression - see ST Criteria)

B. Drugs used for weight loss

  1. Meridia (sibutramine)
  2. Pondimin (fenfluramine)
  3. Ionamin, Adipex-P, or Fastin (phentermine)
  4. Mazanor or Sanorex (mazindol)
  5. Didrex (benzphetamine)
  6. Adipost (phendimetrazine)
  7. Tenuate (diethylpropion)
  8. Xenical (orlistat)

C. Drugs used to treat erectile dysfunction

  1. Viagra
  2. Caverject
  3. MUSE
  4. EDEX
  5. Levitra

D. Drugs used to treat infertility

  1. Antagon (ganirelix)
  2. Lutrepulse (gonadorelin)
  3. Profasi or Pregnyl (HCG)
  4. Follistim (follitropin beta)
  5. Gonal-F (follitropin alfa)
  6. Fertinex (urofollitropin)
  7. Pergonal or Humegon (menotropins)
  8. Clomid or Serophene (clomiphene)

E. Drugs used to treat hair loss

  1. Propecia
  2. Rogaine

F. Drugs considered investigational

G. Drugs for international travel

III. Drug Prior Authorization

Contact the BCBSNM Health Services department to request drug prior authorization. Changes to the prior authorization list are shown here and also published in the Provider News Brief newsletter.

BCBSNM and HMONM allow for certain off-label uses of drugs when the off-label use has reputable medical literature supporting its safe and effective use. BCBSNM uses the following criteria in evaluating off-label medication use:

  • Drug must be approved by the FDA for at least one indication
  • Drug must be prescribed by a participating licensed health care provider within scope of practice
  • With most benefits, drugs in clinical phase 1 or 2 trials are considered experimental and therefore not a covered benefit

Note: Not all medication requiring prior authorization may appear on this list. Many plans have "global" restrictions on such things as injectable products. Refer these type of requests to Health Services.

Note: For all medications on the preauthorization list:

  • Hypersensitivity to any of the medications is a contraindication for use
  • Inclusion in the list by itself does not imply that the drug list will be approved
  • Uses other than those defined in the criteria must meet the BCBSNM/HMONM criteria for approval of new technologies and off-label use

A. Medications Requiring Prior Authorization

1. Celebrex (celecoxib) and Bextra (valdecoxib) Step Therapy Criteria

  1. Age 50 years old or greater or
  2. 30-day trial of one generic NSAID in the last 180 days or
  3. Currently on GI, steroid, or anticoagulant therapy

Duration: 12 months

2. Diflucan (fluconazole)

  1. Oropharyngeal and esophageal candidiasis or
  2. Treatment of serious systematic candida infections including urinary tract infection, peritonitis, or pneumonia or
  3. Cryptococcal meningitis or
  4. Adjunctive AIDS therapy or
  5. Prophylactic therapy for patients receiving radiation or chemotherapy or
  6. Vaginal candidiasis (therapy limited to two 150mg tablets per 30 days) or
  7. Onychomycosis; 150 to 300mg/wk for 3 to 6 months: one course per lifetime as documented by BCBSNM - includes Sporanox and Lamisil

Duration: 1 course of therapy

3. Enbrel (etanercept)

  1. Diagnosis of moderate to severe rheumatoid arthritis or psoriatic arthritis by rheumatologist
  2. Therapeutic failure of adequate trial of at least one of the following:
    • Plaquenil (hydroxychloroquine)
    • Solganal or Ridaura (gold)
    • Methotrexate
    • Imuran (azathioprine)
    • Cuprimine (penicillimine)
    • Azulfidine (sulfasalazine)
    • Arava (leflunomide)

Duration: 6 months initial, for a quantity of 8 per month; re-evaluate every 6 months

4. Forteo (teriparatide)

  1. Verified diagnosis of osteoporosis and
  2. has failed trial of one other osteoporosis therapy (Fosamax, Actonel, Miacalcin)

Duration: 1 year; maximum therapy of 2 years

5. Growth Hormone -- Protropin (somatren), Humatrope, Genotropin, Norditropin, Nutropin, Nutropin AQ, Nutropin-Depot (somatropin)

  1. Diagnosis of neonatal hypopituitarism and hypoglycemia or
  2. Proven growth deficiency in children or
    • fail two provocative growth hormone stimulation tests (L-dopa, clonidine, glucagon, propranolol, arginine, or insulin) (24-hour monitoring of IGF or IGFBP are considered experimental) and
    • have a height >2.5 standard deviations below the median for age or
    • growth velocity is below the 10th percentile when compared with expected growth velocity for chronological age using standard growth chart with at least 3 data points to indicate velocity and
    • a yearly growth rate of <4.5 cm/yr and a bone age of two standard deviations below chronological age
  3. Growth hormone deficiency in adults or
    • have no contraindications to therapy; active malignancy, benign intracranial hypertension, proliferative or pre-proliferative diabetic retinopathy and
    • negative response to standard growth hormone stimulation test and
    • growth hormone deficiency syndrome alone or with multiple hormone deficiencies (hypopituitarism) as a result of pituitary disease, hypothalamic disease, surgery, or radiation therapy or
    • growth hormone deficiency during childhood with growth hormone deficiency syndrome confirmed as an adult before replacement therapy with somatropin is started. Approximate physiologic dose 10mcg/kg/day
  4. Turner's Syndrome or
    • defined as a 45 x0 genotype
    • therapy as defined for growth hormone deficiency in children
  5. Children with chronic renal insufficiency or
    • creatinine clearance less than 75ml/min with height less than 3rd percentile or on hemodialysis
    • in chronic renal failure, therapy is discontinued at the time of kidney transplant
  6. AIDS wasting or cachexia or
    • 10% of baseline weight loss that cannot be explained by concurrent illness other than HIV infection
    • must be on HIV antiviral therapy
    • discontinued when conditions are no longer met
  7. Full-thickness skin loss associated with third degree burn NOS or
    • not have had significant side effects and
    • be compliant with therapy
    • have a growth velocity of >2.5cm/yr in the first 6 months and >4.5cm/yr or more thereafter in children. Usually discontinued around 13 to 16 years of age when growth velocity is less that 2cm/yr, when epiphyseal fusion occurs, or when height reaches 5th percentile of expected adult height based upon mean height of parents
    • growth hormone distribution may be approved through home health agencies or pharmacies
  8. Prader-Willi Syndrome

Duration: 6 months

Current therapies considered investigational for Growth Hormone:

  • Non-growth hormone deficient short stature - except Turner's syndrome
  • Therapy for geriatric patients
  • Anabolic therapy - except for AIDS wasting
  • Acute or chronic catabolic illness
  • Glucocorticoid-induced growth failure
  • Intrauterine growth retardation
  • Short stature after renal transplant
  • Down or Noonan syndromes

6. Humira (adalimumab)

  1. Diagnosis of moderate to severe rheumatoid arthritis by rheumatologist
  2. Therapeutic failure of adequate trial of at least one of the following:
    • Plaquenil (hydroxychloroquine)
    • Sologanal or Ridaura (gold)
    • Methotrexate
    • Imuran (azathioprine)
    • Cuprimine (penicillimine)
    • Azulfidine (sulfasalazine)
    • Arava (leflunomide)

Duration: 6 months initial; 12 months thereafter

7. Infergen (interferon alfacon-1)

  1. 18 years and
  2. Chronic hepatitis non A, non B (C) or
  3. Hairy cell leukemia

Duration: 6 months

8. Intron-A (interferon alfa 2b)

  1. 18 years and
  2. Hairy cell leukemia or
  3. AIDS-related Kaposi's sarcoma or
  4. Chronic hepatitis non A, non B (C) or
  5. Chronic hepatitis B, serum HBe Ag positive or
  6. Condylomata acuminata involving external surfaces of the genital or perianal area or
  7. Chronic myelogenous leukemia, CML (Philadelphia chromosome-positive) or
  8. Multiple myeloma or
  9. Non-Hodgkin's lymphoma, low- or intermediate-grade disease or
  10. Malignant melanoma or
  11. Consult with medical director for the following unlabeled uses:
    • Bladder tumors
    • Carcinoid tumors
    • Cytomegaloviruses
    • Essential thrombocythemia
    • Cutaneous T-cell lymphoma
    • Cutaneous warts
    • Herpes keratoconjunctivitis

Duration: 6 months

9. Kineret (anakinra)

  1. Diagnosis of moderate to severe rheumatoid arthritis by rheumatologist
  2. Not currently on Enbrel or Remicade
  3. Therapeutic failure of adequate trial of at least one of the following:
    • Plaquenil (hydroxychloroquine)
    • Solganal or Ridaura (gold)
    • Methotrexate
    • Imuran (azathioprine)
    • Cuprimine (penicillimine)
    • Azulfidine (sulfasalazine)
    • Arava (leflunomide)

Duration: 6 months initial, for a quantity of 30 100mg injections per month; 12 months thereafter

10. Lamisil (terbinafine)

  1. Fingernail onychomycosis; 6-week course of therapy; one course per lifetime as documented by BCBSNM - includes Sporanox and Diflucan - or
  2. Toenail onychomycosis; 12-week course of therapy; one course per lifetime as documented by BCBSNM - includes Sporanox and Diflucan

11. Neupogen, G-CSF (filgrastim) and Neulasta (pegfilgrastin)

  1. Treatment of chemotherapy-induced neutropenia in non-myeloid malignancies or
  2. Prophylaxis in Cytotoxic chemotherapy of high intensity where neutropenia is expected or
  3. Neutropenia associated with HIV or
  4. Aplastic anemia or
  5. Alloimmune neonatal neutropenia or
  6. Congenital or drug-induced agranulocytosis

Not to be approved to "prime" responses to chemotherapy in patients by administrating prior to and/or concurrent with chemotherapy.

Duration: 3 months

12. Pegasys (peginterferon alfa-2a) and Pegintron (peginterferon alfa-2b)

  1. Diagnosis by gastroenterologist of chronic hepatitis C in patients with compensated liver disease and meets the following criteria:
    • Patient seropositive for HCV RNA and
    • Elevated serum alanine aminotransferase

Do not approve in patients with decompensated cirrhosis.
Refer to medical director for use during pregnancy.

Duration: 6 months; may be renewed one additional time only

13. Pulmazyme, rhDNAse (Dornase Alfa)

  1. Diagnosis of Cystic Fibrosis
    • Five years of age or older and
    • Baseline forced vital capacity (FVC) >40% of predicted

Duration: 1 year; once daily dosing only

14. Procrit, Epogen (erythropoietin) and Aranesp (darbepoetin alpha)

  1. Anemia of chronic renal failure or
  2. Anemia with HIV infection and retrovir, AZT therapy < 4200mg/w or
  3. Chemotherapy induced anemia with non-myeloid malignancy or
  4. Reduction of allogeneic blood transfusion in surgery patients

Duration: 3 months

15. Rebetron (ribavirin and interferon alfa-2b)

  1. Diagnosis by gastroenterologist of chronic hepatitis C in patients with compensated liver disease and meets the following criteria:
    • Patient seropositive for HCV RNA and
    • Elevated serum alanine aminotransferase

Do not approve in patients with decompensated cirrhosis.
Refer to medical director for use during pregnancy.

Duration: 6 months; may be renewed one additional time only

16. Rebif (interferon beta 1a)

  1. Diagnosis of relapsing, remitting multiple sclerosis (RRMS) only

Duration: 6 months; 12 single-dose syringes per 30 days

17. Remicade (infliximab)

  1. Moderate to severe Crohn's disease.
    Required documentation:
    • Trial of mesalamine (Asacol or Pentasa) for at least 8 weeks or
    • Trial of oral corticosteroids for at least 8 weeks or
    • Trial of mercaptopurine for at least 6 months or
    • Trial of azathioprine for at least 6 months
    Duration: Single dose, 5mg/kg IV over 2 hours

  2. Fistulizing Crohn's disease
    Duration: 3 doses of 5mg/kg over 6 weeks (initial, at 2 weeks and 6 weeks)

  3. Diagnosis of moderate to severe rheumatoid arthritis and
    • Significant joint involvement (12 tender or 10 swollen joints) and
    • Inadequate therapeutic response to methotrexate
    Duration: 3 mg/kg dose at zero, 2, and 6 weeks. Every 8 weeks thereafter. Approve for 6 months then re-evaluate.

18. Retin-A or Avita (tretinoin)

  1. Member age > 40 years and
  2. Acne Vulgaris or
  3. Actinic Keratosis

Duration: 1 year

19. Renova - Not covered; is only indicated for cosmetic purposes

20. Roferon-A (interferon alfa 2a)

  1. 18 years and
  2. Hairy cell leukemia or
  3. AIDS-related Kaposi's sarcoma or
  4. Chronic hepatitis non A, non B (C) or
  5. Chronic hepatitis B, serum HBe Ag positive or
  6. Condylomata acuminata involving external surfaces of the genital or perianal area or
  7. Chronic myelogenous leukemia, CML (Philadelphia chromosome-positive) or
  8. Multiple myeloma or
  9. Non-Hodgkin's lymphoma, low- or intermediate-grade disease or
  10. Malignant melanoma or
  11. Consult with medical director for the following unlabeled uses:
    • Bladder tumors
    • Carcinoid tumors
    • Cytomegaloviruses
    • Essential thrombocythemia
    • Cutaneous T-cell lymphoma
    • Cutaneous warts
    • Herpes keratoconjunctivitis

Duration: 6 months

21. Sporanox (itraconazole)

  1. Documented histoplasmosis or blastomycosis infection or
  2. Aspergillosis in patients who are intolerant of or refractory to amphotericin B therapy or
  3. Fingernail onychomycosis; 6-week course of therapy; one course per lifetime as documented by BCBSNM - includes Lamisil and Diflucan - or
  4. Toenail onychomycosis; 12-week course of therapy; one course per lifetime as documented by BCBSNM - includes Lamisil and Diflucan

22. Tazorac (tazarotene topical gel)

  1. Member age >40 years and
  2. Diagnosis of Psoriasis or
  3. Acne Vulgaris or
  4. Actinic Keratosis

Duration: 1 year

23. Testosterone (AndroGel, AndroDerm, TestoDerm, Striant)

  1. Restricted to males with documented low serum testosterone

Duration: 1 year

24. Thalomid (thalidomide)

Thalidomide is approved for marketing only under a special restricted distribution program approved by the FDA called "System for Thalidomide Education and Prescribing Safety" (STEPS). Only program-registered pharmacists and prescribers are allowed to possess and use the product. Multiple trials are being conducted over a broad range of diseases states. Many of these trials are still in phase I and II testing and therefore considered investigational.

  1. Diagnosis of one of the following:
    • Erythema nodosum leprosum (ENL) (currently only approved indication)
    • Multiple myeloma

Duration: Course of therapy

25. Vfend (voriconazole)

  1. Restricted to treatment of
    • Invasive Aspergillosis or
    • Serious infections caused by fusarium species or S. apiospermum

Duration: 30 days

26. Vioxx (rofecoxib) Step Therapy Criteria

  1. Age 50 years old or greater or
  2. 30-day trial of one generic NSAID in the last 180 days or
  3. Concomitant use of an anti-secretory medication (e.g. Prilosec), steroid, or anticoagulant therapy

Duration: 12 months

27. Wellbutrin SR and XL (bupropion) Step Therapy Criteria

  1. Age 18 years old or less
  2. Trial of one SSRI, atypical antidepressant or Zyprexa in last 180 days

Duration: 1 year

28. Xolair (omalizumab)

  1. Patient with severe persistent asthma who falls within recommended dosing guidelines with:
    • Age ≥ 12 years old and
    • Weight less than 150kg and
    • IgE serum levels less than 700iu and
    • FEV-1 <80%

Duration: 6 months

29. Zyvox (linezolid)

  1. Culture and sensitivities verifying:
    • Vancomycin resistant Enterococcus faecium or Enterococcus faecalis or
    • Methicillin resistant Staphylococcus aureus or
    • Methicillin resistant Streptococcus pyogenes or Streptococcus agalactiae

Duration: Maximum duration of therapy is 14 days including inpatient therapy

Note: If you are not a health care professional, you should understand that the information presented is intended and designed for use by an expert audience. You should seek assistance from a health care professional in interpreting these materials and applying them in individual cases.

 

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