Blue Cross Blue Shield of New Mexico Drug Prior Authorization Form

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Medication Authorization Request Forms for Drugs Covered Under the Medical Benefit

On this page you'll find information for:

• BCN HMO ^SM (commercial)
• BCN Advantage ^SM
• Blue Cross commercial
• Blue Cross Medicare Plus Blue ^SM PPO
• Blue Cross Federal Employee Program^®

BCN HMO SM (Commercial) Forms
Blue Cross Commercial Forms
Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form.
Actemra® Acthar Gel® Adakveo® Alpha 1-Proteinase Inhibitors (use this form for all medications listed below) Aralast NP Glassia Prolastin-C® Zemaira® Amondys 45 Bavencio® (*See note below.) Beleodaq® Benlysta® Botulinum Botox® Dysport™ Myobloc® Xeomin® Brineura® Cimzia® Cinqair® Colony Stimulating Factors Fulphila® Granix® Neupogen® Udenyca® Ziextenzo® Crysvita® Dysport™ Empaveli™ Entyvio® Enzyme replacement therapy Adagen® Aldurazyme® Cerezyme® Elaprase® Elelyso® Fabrazyme® Kanuma® Lumizyme® Mepsevii™ Naglazyme® Nexviazyme™ Vimizim® Vpriv® Evenity™ Evkeeza™ Exondys 51® Fasenra™ Givlaari™ (*See note below.) HAE (use this form for all medications listed below) Berinert® Cinryze® Firazyr® Kalbitor® Ruconest® Sajazir Hemlibra® Ilaris® Ilumya™ Imfinzi (*See note below.) Infliximab Products Avsola™ Inflectra™ Remicade® Renflexis™ Intravitreal Injection Beovu® Eylea® Lucentis® Macugen® Susvimo™ Vabysmo™ IVIG (use this form for all medications listed below) Asceniv™ Bivigam® Carimune NF® Cutaquig® Cuvitru™ Flebogamma DIF® Gammagard Liquid® Gammagard S/D® Gammaked Gammaplex® Gamunex® Hizentra® Hyqvia® Ig, IV injection NOS Octagam® Panzyga® Privigen® Xembify	Krystexxa® Kymriah Lemtrada® Leqvio® Levoleucovorin Injection Fusilev® Khapzory™ Luxturna™ Makena® Myobloc® Nplate® Nucala® Nulibry™ Ocrevus® Oncology Biosimilar Onpattro™ Orencia® Oxluma™ Palforzia™ Poteligeo® (*See note below.) Prolia™ Radicava® Reblozyl® Ryplazim® Saphnelo™ Scenesse® Signifor® LAR Simponi Aria® Skyrizi™ Soliris® Spinraza™ Spravato™ Stelara SC® Stelara® IV Synagis® Tegsedi® Tepezza™ Testosterone (use this form for all medications listed below) Aveed® Testopel® Tezspire™ Trogarzo™ Tysabri® Ultomiris™ Uplizna™ Vyepti™ Vyvgart™ Xeomin® Xgeva® Xiaflex® Xolair® Yescarta® Zilretta® Zinplava™ Zolgensma®
* Note: The drugs that have an asterisk no longer require prior authorization. The form should be used only when requesting a retroactive authorization for the drug.

BCN Advantage SM Forms
Blue Cross Medicare Plus Blue SM PPO Forms
Go to the BCN Advantage medical drug policies and forms page.
Go to the Medicare Advantage PPO medical drug policies and forms page.

Blue Cross Federal Employee Program®
Use these forms to obtain prior authorization for administering medications in physician's offices and outpatient hospitals, including urgent care, hospital-based infusion care centers, and clinics where the drug is injected or infused and billed on a UB04 or CMS 1500 form.
Actemra IV® Actemra SC® Alpha 1-Proteinase Inhibitors (use this form for all medications listed below) Aralast NP Glassia Prolastin-C® Zemaira® Benlysta® Beovu® Botox® Brineura Cimzia® Cinqair® Crysvita® Dysport Enzyme replacement therapy Adagen® Aldurazyme® Cerezyme® Elaprase® Elelyso® Fabrazyme® Kanuma Lumizyme® Naglazyme® Vimizim Vpriv® Entyvio® Evenity Exondys 51 Eylea® Fasenra Fusilev HAE Berinert® Cinryze® Kalbitor Ruconest Hemlibra® Ilaris® Ilumya Inflectra IVIG Asceniv Bivigam® Carimune NF® Cutaquig® Cuvitru Flebogamma DIF® Gammagard Liquid® Gammagard S/D® Gammaked Gammaplex® Gamunex® Hizentra® Hyqvia® Octagam® Panzyga Privigen® Xembify®	Khapzory Krystexxa® Kymriah Lemtrada® Lucentis® Luxturna Macugen® Makena Mepsevii Myobloc® Nplate® Nucala® Ocrevus Onpattro Orencia IV® Orencia SC® Prolia Radicava Remicade® Renflexis Signifor® LAR Simponi® Aria Soliris® Spinraza Spravato Stelara Synagis® Testosterone Aveed® Testopel® Trogarzo Tysabri® Ultimoris Xeomin® Xgeva® Xiaflex® Xolair® Yescarta® Zilretta® Zolgensma®



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