Pharmacy and Drug Information

Welcome to the Pharmacy and Drug Information page for providers. Here you will find essential resources and links to help you manage patient medications and understand the pharmacy benefits available.

Molina Healthcare of New Mexico offers a comprehensive list of covered medications for Members in alignment with all state requirements.  The list shows all the prescription and over-the-counter products Members can get from a pharmacy.  Some medications require prior authorization (PA) or have limitations on age, dosage and/or quantities.

    NM Turquoise Care Preferred Drug List - Downloadable PDF

    NM Turquoise Care Preferred Drug List Searchable Tool 

    Preferred Drug List Updates

    Pharmacy PA Systems Downtime Notice 2024

    Prior Authorizations

    Molina’s decisions are based upon the information included with the PA request. Clinical notes are recommended.

    Pharmacy Prior Authorization Forms

   Prior Authorizations Criteria

Abilify MyCite Kit (aripiprazole tablets with sensor) MNR

Actemra (tocilizumab) and Biosimilars

Acthar-Gel-repository-corticotropin-injection-C8373-A

Adakveo (crizanlizumab-tmca)

Adbry (tralokinumab-ldrm)

Adcetris (brentuximab vedotin)

Aduhelm (aducanumab-avwa)

Adzynma (ADAMTS13, recombinant-krhn)

Agamree (vamorolone)

Aldara/Zyclara (imiquimod)

Alpha-1-Antitrypsin-AAT-Deficiency-Enzyme-C8797-A

Amondys 45 (casimersen) MNR

Ampyra (dalfampridine)

Amvuttra (vutrisiran)

Antidiabetic Agents

Antiemetics

Antimalarial Agents

Aphexda (motixafortide)

Apokyn, Kynmobi (apomorphine)

Arcalyst-rilonacept-C2434-A

Arixtra (fondaparinux)

Atypical Antipsychotics

Austedo (deutetrabenazine)

Azactam (aztreonam)

Baxdela (delafloxacin)

Benlysta (belimumab)

Beovu (brolucizumab)

Bimzelx (bimekizumab-bkzx)

Botulinum Toxin

Brineura (cerliponase alfa)

Briumvi (ublituximab-xiiy)

Brixadi (buprenorphine extended release inj)

Buprenorphine-Naloxone and Buprenorphine for Opioid Dependence

Bylvay (odevixibat)

Cablivi (caplacizumab-yhdp)

Calcitonin Gene-Related Peptide (CGRP) Antagonist

Camzyos (mavacamten)

Cancidas (caspofungin)

Carisoprodol Products

Cayston (aztreonam)

Cerdelga (eliglustat)

Chemet (succimer)

Cholbam (cholic acid)

Cibinqo (abrocitinib)

Cimzia (certolizumab pegol)

Cinqair (reslizumab)

CNS Stimulants

Colcrys, Mitigare, Gloperba (colchicine)

Constipation Agents

Continuous Glucose Monitoring Systems (CGMS)

Copaxone/Glatopa (glatiramer acetate)

Cosela (trilaciclib)

Cosentyx (secukinumab)

Crysvita (burosumab-twza)

Cubicin (daptomycin)

Cuvposa (glycopyrrolate) Oral Solution

Cystic Fibrosis Agents

Cytogam (cytomegalovirus immune globulin)

Dalvance (dalbavancin)

Daraprim (pyrimethamine)

Daybue (trofinetide)

Desmopressin Nasal and Oral (DDAVP)

Dextenza (dexamethasone intracanalicular insert)

Dexycu (dexamethasone intraocular suspension)

Diabetic Testing Supplies

Diclofenac Topical

Direct Oral Anticoagulants

Disposable Insulin Delivery Device

Doptelet (avatrombopag)

Dry Eye Therapies

Dupixent (dupilumab)

Duplication of Therapy/High Risk Combination

Durysta (bimatoprost implant)

Egrifta SV (tesamorelin) MNR

Elaprase (idursulfase)

Elfabrio (pegunigalsidase alfa)

Elidel-Protopic-Eucrisa

Eltrombopag (Alvaiz, Promacta)

Emflaza (deflazacort) MNR

Empaveli (pegcetacoplan)

Enbrel (etanercept)

Endari (L-glutamine) MNR

Enjaymo (sutimlimab-jome)

Enspryng (satralizumab-mwge)

Entresto (sacubitril/valsartan)

Entyvio (vedolizumab)

Enzyme Replacement Therapy for Gaucher Disease

Enzyme Replacement Therapy for Lysosomal Storage

Eohilia (budesonide oral suspension)

Epidiolex (cannabidiol)

Erythropoiesis-stimulating agents (ESAs)

Esbriet (pirfenidone)

Evenity (romosozumab-aqqg)

Evkeeza (evinacumab-dgnb)

Evrysdi (risdiplam)

Exondys 51 (eteplirsen) MNR

Eylea (aflibercept)

Fabhalta (iptacopan)

Fabrazyme (agalsidase beta)

Fasenra (benralizumab)

Filgrastim

Filspari (sparsentan)

Filsuvez (birch triterpenes gel)

Firdapse (amifampridine)

Forteo (teriparatide)

Furoscix (furosemide injection)

Fuzeon (enfuvirtide)

Galafold (migalastat)

Gamifant (emapalumab-lzsg)

Gattex (teduglutide [rDNA origin])

Gender Dysphoria Hormone Therapy

Givlaari (givosiran)

Global Formulary Exception Criteria (NF, QL, ST, etc.)

Gocovri/Osmolex (amantadine ER caps/tabs)

Growth Hormone (somatropin and analogs) Therapy

Hemophilia and Blood Factor Products

Hemostatic Agents

Hep B Immune Globulin

Hepatitis C Antiviral Therapy

Hereditary Angioedema Agents

Hetlioz (tasimelteon)

High-Cost Outlier Targeted Drug Exception

Humira (adalimumab) and Biosimilars

Hyaluronic Acid Injections

iDose TR (travoprost intracameral implant)

Igalmi (dexmedetomidine)

Ilaris (canakinumab)

Ilumya (tildrakizumab)

Iluvien (fluocinolone acetonide intravitreal implant

Immunoglobulin (SCIg, IVIg) MHI

Impetigo Agents: Altabax (retapamulin), Bactroban_Centany

Increlex (mecasermin)

Infliximab and Biosimilars

Ingrezza (valbenazine)

Inpefa (sotagliflozin)

Inrebic (fedratinib)

Intravenous Bisphosphonates

Iron Chelating Agents (Desferal, Exjade, Ferriprox, Jadenu)

Iron Deficiency Anemia Agents

Isotretinoin

Isturisa (osilodrostat)

Izervay (avacincaptad intravitreal)

Jakafi (ruxolitinib)

Jesduvroq (daprodustat)

Joenja (leniolisib)

Juxtapid (lomitapide)

Kanuma (sebelipase alfa)

Kerendia (finerenone)

Kesimpta (ofatumumab)

Keveyis (dichlorphenamide)

Kevzara (sarilumab)

Kineret (anakinra)

Korlym (mifepristone)

Korsuva (difelikefalin)

Koselugo (selumetinib)

Krystexxa (pegloticase)

Kuvan (sapropterin dihydrochloride)

Lamzede (velmanase alfa-tycv)

Lemtrada (alemtuzumab)

Leqembi (lecanemab-irmb)

Leqvio (inclisiran)

Leukine (sargramostim

Leuprolide Long Acting (Camcevi, Eligard, Fensolvi, Lupron Depot, Lupron Depot Ped)

Lidocaine Patch

Linezolid

Litfulo (ritlecitinib) MNR

Livmarli (maralixibat)

Livtencity (maribavir

Lucemyra (lofexidine)

Lumizyme (alglucosidase alfa)

Lupkynis (voclosporin)

Lyrica_Lyrica CR (pregabalin_pregabalin ER)

Medical Necessity Review

Mepron (atovaquone)

Mepsevii (vestronidase alfa-vjbk)

Mozobil (plerixafor)

Mulpleta (lusutrombopag)

Multiple Sclerosis Agents- Interferons

Myalept (metreleptin)

Mycamine (micafungin)

Nasal Steroids

Natpara (parathyroid hormone)

Nexletol (bempedoic acid) and Nexlizet (bempedoic acid and ezetimibe)

NexoBrid (anacaulase-bcdb)

Nexviazyme (avalglucosidase alfa-ngpt

Nitisinone (Orfadin, Nityr)

Northera (droxidopa)

Nplate (romiplostim)

Nucala (mepolizumab)

Nuedexta (dextromethorphan/quinidine)

Nulibry (fosdenopterin)

Nulojix (belatacept)

Nuplazid (pimavanserin)

Nuzyra (omadacycline)

Ocaliva (obeticholic acid)

Ocrevus (ocrelizumab)

Octreotide

Ofev (nintedanib)

Off-Label Use of Drugs and Biologic Agents

Ojjaara (momelotinib)

Olumiant (baricitinib)

Omvoh (mirikizumab-mrkz)

Onpattro (patisiran), Tegsedi (inotersen)

Opfolda (miglustat)

Topical Antibacterials

Opioid Global Criteria

Opzelura (ruxolitinib)

Oral MS Disease-Modifying Therapies

Orencia (abatacept)

Orgovyx (relugolix), Myfembree (relugolix, estradiol, and norethindrone)

Orilissa (elagolix), Oriahnn (elagolix, estradiol, and norethindrone acetate capsules)

Orladeyo (berotralstat)

Otezla (apremilast)

Otrexup, Rasuvo, RediTrex (methotrexate)

Oxbryta (voxelotor)

Oxervate (cenegermin)

Oxlumo (lumasiran)

Ozurdex (dexamethasone intravitreal implant)

Palforzia [Peanut (arachis hypogaea) Allergen Powder-dnfp]

Palynziq (pegvaliase-pqpz)

Parsabiv (etelcalcetide)

PCSK9 Inhibitors (alirocumab, evolocumab)

Penicillamine (Depen, Cuprimine), Trientine (Cuvrior, Syprine)

Physician Administered Drugs

Pombiliti (cipaglucosidase alfa-atga)

Prescription Compounded Product

Prevymis (letermovir)

Procysbi, Cystagon (cysteamine bitartrate)

Prolia (denosumab

Pulmicort Respules (budesonide)

Pulmonary Arterial Hypertension (PAH)

Pulmozyme (dornase alfa)

Pyrukynd (mitapivat)

Qalsody (tofersen)

Qutenza (capsaicin)

Radicava (edaravone)

Ranibizumab and Biosimilars (Lucentis, Byooviz, Cimerli)

Ravicti (glycerol phenylbutyrate)

Reblozyl (luspatercept-aamt)

Rebyota (fecal microbiota, live‐jslm)

Recorlev (levoketoconazole)

Regranex (becaplermin)

Relizorb (immobilized lipase cartridge) MNR

Retisert, Yutiq (fluocinolone acetonide) Intravitreal Implants

Revcovi (elapegademase)

Reyvow (lasmiditan)

Rezurock (belumosudil)

Rezzayo (rezafungin)

Riluzole (Rilutek/Tiglutik/Exservan)

Rinvoq (upadacitinib)

Rituxan (rituximab) and Biosimilars

Rivfloza (nedosiran)

Rolvedon, Neulasta and Related Biosimilars

Ryplazim (human plasminogen)

Rystiggo (rozanolixizumab-noli)

Santyl (collagenase)

Saphnelo (anifrolumab-fnia)

Savella (milnacipran)

Sensipar (cinacalcet)

Serotonin - Norepinephrine Reuptake Inhibitors (SNRI)

Sexual Dysfunction Criteria NC

Seysara (sarecycline)

Signifor (pasireotide diaspartate)

Siliq (brodalumab)

Simponi/Simponi Aria (golimumab)

Sivextro (tedizolid)

Skyclarys (omaveloxolone)

Skyrizi (risankizumab-rzaa)

Sodium Oxybate (Lumryz, Xyrem, Xywav)

Sohonos (palovarotene)

Soliris (eculizumab), Ultomiris (ravulizumab)

Sotyktu (deucravacitinib)

Spevigo (spesolimab-sbzo)

Spiriva (tiotropium)

Sporanox, Tolsura (itraconazole)

Spravato (esketamine)

Standard Oncology Criteria

Stelara (ustekinumab)

Strensiq (asfotase alfa)

Sublocade (buprenorphine extended-release inj.)

Sunlenca (lenacapavir)

Sunosi (solriamfetol)

Supprelin LA (histrelin acetate) Implant

Susvimo (ranibizumab) Intravitreal Implant

Syfovre (pegcetacoplan intravitreal)

Symlin (pramlintide)

Synagis (palivizumab)

Synarel (nafarelin acetate nasal solution)

Tadalafil and Combinations

Taltz (ixekizumab)

Tarpeyo (budesonide)

Tavalisse (fostamatinib)

Tavneos (avacopan)

Tepezza (teprotumumab-trbw)

Testosterone

Tezspire (tezepelumab-ekko)

Thiola (tiopronin)

Tobramycin for Inhalation

Tolvaptan

Topical Acne

Topical Retinoids and Combinations

Tremfya (guselkumab)

Triptodur (triptorelin pamoate)

Trogarzo (ibalizumab-uiyk

Tymlos (abaloparatide)

Tysabri (natalizumab)

Tzield (teplizumab-mzwv)

Uplizna (inebilizumab-cdon)

Vabysmo (faricimab-svoa)

Valcyte (valganciclovir)

Vancocin (vancomycin) Capsules

Veklury (remdesivir)

Velsipity (etrasimod)

Veopoz (pozelimab-bbfg)

Veozah (fezolinetant)

Verquvo (vericiguat)

Vibativ (telavancin)

Vijoice (alpelisib)

Viltepso (viltolarsen) MNR

Vimizim (elosulfase alfa)

Vonjo (pacritinib)

Vowst (fecal microbiota spores, live-brpk)

Voxzogo (vosoritide)

Vtama (tapinarof) Cream

Vyndaqel (tafamidis meglumine), Vyndamax (tafamidis)

Vyondys 53 (golodirsen) MNR

Vyvgart (efgartigimod)

Wainua (eplontersen)

Wakix (pitolisant)

Xacduro (sulbactam/durlobactam)

Xeljanz/Xeljanz XR (tofacitinib)

Xenazine (tetrabenazine)

Xenpozyme (olipudase alfa-rpcp)

Xermelo (telotristat ethyl)

Xgeva (denosumab)

Xiaflex (collagenase clostridium histolyticum)

Xifaxan (rifaximin)_Aemcolo (rifamycin)

Xipere (triamcinolone acetonide ocular inj)

Xolair (omalizumab)

Xphozah (tenapanor)

Zavesca (miglustat)

Zemplar (paricalcitol)

Zilbrysq (zilucoplan)

Zilretta (triamcinolone acetonide ER injection)

Zinplava (bezlotoxumab)

Zokinvy (lonafarnib)

Zoladex (goserelin acetate)

Zortress (everolimus)

Zoryve (roflumilast) Cream

Zovirax (acyclovir) Topical

Ztalmy (ganaxolone)

Zulresso (brexanolone)

Zurzuvae (zuranolone)

 

Step Therapy

Plan restrictions for certain Formulary drugs may require that other drugs be tried first. New Mexico Medicaid’s Preferred Drug List (PDL) designates which drugs require step therapy. Drug samples from Providers or manufacturers are not considered as meeting step therapy requirements or as justification for exception requests.

 

Pharmacy Billing

 

MAC Pricing (Maximum Allowable Cost) Pharmacists & Medical Professionals | CVS Caremark

    Molina Pharmacy New Mexico Implementation Guide

    Physicians-Administered (J-codes) Medications

    COVID Billing Vaccine Guidance

 

Drug Recall Information