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Changes Coming to the Medical Drug Benefit Program
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 15, 2026
Summary
Effective January 1, 2027, Blue Cross and Blue Shield of New Mexico is expanding its Medical Drug Benefit Program to update coverage for prescription drugs administered by healthcare providers in clinical settings. The program now defines coverage for therapeutic alternatives, new-to-market drugs, FDA-accelerated approval drugs, and drugs with limited medical benefit coverage. This change applies only to commercial members and does not affect Medicaid, HMO, Federal Employee Program, or Postal Employee Program members.
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What to do
by Jan 1, 2027 · 5 steps
01Billing team should review the Medical Drug Benefit Program Summary to identify which drugs are included in the expanded program.
02Providers should verify eligibility and benefits through Availity Essentials or preferred vendor prior to rendering services to confirm prior authorization requirements and applicable utilization management vendors.
03Implement prior authorization submission processes for drugs identified in the Medical Drug Benefit Program's prior authorization code lists.
04For drugs not covered under the program, establish a workflow to submit exception requests using the Medical Drug Benefit Program exception form when medically necessary.
05Update internal documentation and staff training to reflect that new-to-market drugs, FDA-accelerated approval drugs, and therapeutic alternatives require review before coverage is determined.
Original notice
Changes Coming to the Medical Drug Benefit Program
bcbsnm.com · Always check the source before changing claims.