Drug Coverage - Frequently Asked Questions

The New Mexico Health Care Authority (HCA) makes the decision about which drugs will be covered for the Medicaid program. BCBSNM is required to cover drugs that are on the HCA Preferred Drug List (PDL). In most cases only the drugs on the list are covered. A prescription drug list is sometimes called a formulary. Drugs are evaluated based for benefit, safety, and cost before including them on the list. Your doctor should consult the Preferred Drug List when prescribing drugs for you.

Usually only drugs on the Preferred Drug List are covered. However, if you or your doctor have questions about a drug not on the list, call Member Services at 1-866-689-1523.

Specialty pharmacy drugs are used to treat serious and/or chronic conditions. Examples of serious conditions are:

• multiple sclerosis
• hepatitis
• 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

Learn about generic drugs

OTC medicines are drugs that can be sold without a prescription. Please note: BCBSNM will pay for some OTC drugs for Turquoise Care 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
• Members must have a prescription from their doctor to get any approved OTC drug.

Certain drugs require approval from BCBSNM. This approval is called "prior authorization." If approval is not obtained, BCBSNM will not pay for them. The list of drugs that require approval is in the Preferred Drug List. To request approval, your doctor must call the BCBSNM's pharmacy benefit manager, Prime Therapeutics^®1, at 1-855-457-0755.

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, they can call BCBSNM’s pharmacy benefit manager, Prime Therapeutics, at 1-855-457-0755.

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 they prescribe 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 Preferred Drug List is right for you. If you have any questions about your prescription drug plan, call Member Services at 1-866-689-1523.