2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-50.4 - Prescription drugs; prohibited formulary changes; notice requirements.

A. As of January 1, 2014, an individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides prescription drug benefits categorized or tiered for purposes of cost-sharing through deductibles or coinsurance obligations shall not make any of the following changes to coverage for a prescription drug within one hundred twenty days of any previous change to coverage for that prescription drug, unless a generic version of the prescription drug is available:
(1) reclassify a drug to a higher tier of the formulary;
(2) reclassify a drug from a preferred classification to a non-preferred classification, unless that reclassification results in the drug moving to a lower tier of the formulary;
(3) increase the cost-sharing, copayment, deductible or co-insurance charges for a drug;
(4) remove a drug from the formulary;
(5) establish a prior authorization requirement;
(6) impose or modify a drug's quantity limit; or
(7) impose a step-therapy restriction.
B. The health maintenance organization shall give the affected subscriber at least sixty days' advance written notice of the impending change when it is determined that one of the following modifications will be made to a formulary:
(1) reclassification of a drug to a higher tier of the formulary;
(2) reclassification of a drug from a preferred classification to a non-preferred classification, unless that reclassification results in the drug moving to a lower tier of the formulary;
(3) an increase in the cost-sharing, copayment, deductible or coinsurance charges for a drug;
(4) removal of a drug from the formulary;
(5) addition of a prior authorization requirement;
(6) imposition or modification of a drug's quantity limit; or
(7) imposition of a step-therapy restriction for a drug.
C. Notwithstanding the provisions of Subsections A and B of this section, the health maintenance organization may immediately and without prior notice remove a drug from the formulary if the drug:
(1) is deemed unsafe by the federal food and drug administration; or
(2) has been removed from the market for any reason.
D. The health maintenance organization shall provide to each affected subscriber the following information in plain language regarding prescription drug benefits:
(1) notice that the health maintenance organization uses one or more drug formularies;
(2) an explanation of what the drug formulary is;
(3) a statement regarding the method the health maintenance organization uses to determine the prescription drugs to be included in or excluded from a drug formulary; and
(4) a statement of how often the health maintenance organization reviews the contents of each drug formulary.
E. As used in this section:
(1) "formulary" means the list of prescription drugs covered pursuant to a health maintenance organization contract; and
(2) "step therapy" means a protocol that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular patient are to be prescribed.
History:
Laws 2013, ch. 138, § 4.
ANNOTATIONS
Effective dates.
— Laws 2013, ch. contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 14, 2013, 90 days after the adjournment of the legislature.