Pharmacy Program Update: Utilization Management Transition

The Blue Cross and Blue Shield of New Mexico (BCBSNM) pharmacy optimization initiative includes a number of strategies to help improve the value of our drug benefits, monitor drug safety and ultimately improve health outcomes for our members.

Effective January 1, 2012, Prime Therapeutics will begin conducting all prior authorization (PA) and step therapy (ST) requests from physicians for BCBSNM commercial members with prescription drug coverage administered by Prime. This means that, instead of contacting BCBSNM Pharmacy Services, you will be required to complete and submit a preauthorization request form to Prime for all specified PA and ST medications for commercial members. Please continue to contact BCBSNM for all BlueSalud preauthorization requests.

As of January 1, 2012, a new BCBSNM Preauthorization Request Physician Fax Form for each PA and ST medication requiring preauthorization will be available in the Pharmacy Program section of our website. Please note that, when you select the PA and ST Preauthorization Request Physician Fax Forms link, you will be directed to the Prime Therapeutics site. This will help ensure that you always have access to the most current information.

New Contact Information for PA/ST Preauthorization Requests

The following information is effective beginning January 1, 2012:

• BCBSNM Pharmacy Services will no longer be handling PA and ST preauthorization requests
• The fax number for submitting completed PA and ST Preauthorization Request Physician Fax Forms to Prime Therapeutics is 877-243-6930
• The telephone number for Prime’s Clinical Review Department is 800-544-1378

Remember to discard any PA and ST preauthorization request fax forms that you may have printed or downloaded prior to January 1, 2012, as they will not reflect the correct information.

PA and ST programs may not apply to all prescription drug benefit plans. To determine if a specific benefit plan includes a PA or ST program, and which drug categories are included in the member's plan, call the Pharmacy Program number listed on the back of the member's ID card. Benefits will continue to be available for medications if warranted by the patient’s medical history and current medical condition. The final decision regarding what medicines should be prescribed, regardless of the benefit determination, is a decision between the patient and their doctor.

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

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