2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 61 - Pharmacy Benefits Manager Regulation › Section 59A-61-4 - Pharmacy reimbursement practices for generic drugs; appeals process required.

A. A pharmacy benefits manager shall determine a reimbursement amount for a generic drug based on objective and verifiable sources.
B. A pharmacy benefits manager shall reimburse a pharmacy an amount no less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate in the same network for providing the same or equivalent service.
C. A pharmacy benefits manager using maximum allowable cost pricing may place a drug on a maximum allowable cost list if the drug:
(1) is listed as "A" or "B" rated in the most recent version of the United States food and drug administration's approved drug products with therapeutic equivalence evaluations, also known as the "orange book", or has an "NR" or "NA" rating or a similar rating by a nationally recognized reference;
(2) is available for purchase by pharmacies in the state at the time of claim submission from national or regional wholesalers and is not obsolete; and
(3) is a drug with not fewer than two "A" or "B" rated therapeutically equivalent drugs in the most recent version of the United States food and drug administration's approved drug products with therapeutic equivalence evaluations, also known as the "orange book".
D. A pharmacy benefits manager using maximum allowable cost pricing shall:
(1) upon a network pharmacy's request, provide that network pharmacy with the sources used to determine the maximum allowable cost pricing for the maximum allowable cost list specific to that provider;
(2) review and update maximum allowable cost price information at least once every seven business days to reflect any modification of maximum allowable cost pricing;
(3) establish and maintain a process for eliminating products from the maximum allowable cost list or modifying maximum allowable cost prices in at least seven business days to remain consistent with pricing changes and product availability in the marketplace;
(4) provide a procedure that allows a pharmacy to choose the entity to which it will appeal reimbursement for generic drugs. A pharmacy may appeal:
(a) directly to the pharmacy benefits manager; or
(b) through a pharmacy services administrative organization;
(5) provide an appeals process that, at a minimum, includes the following:
(a) a dedicated telephone number and electronic mail address or website for the purpose of submitting appeals;
(b) the ability to submit an appeal directly to the pharmacy benefits manager; and
(c) the allowance of at least twenty-one business days to file an appeal after the date a pharmacy receives notice of the reimbursement amount;
(6) grant an appeal if the pharmacy benefits manager fails to respond to a complete submission as defined by rules promulgated by the superintendent of the appealing party in writing within fourteen business days after the pharmacy benefits manager receives the appeal;
(7) if an appeal is granted, notify the challenging pharmacy and its pharmacy services administrative organization, if any, that the appeal is granted and make the change in the maximum allowable cost effective for the appealing pharmacy and for each other pharmacy in its network and permit the appealing pharmacy to reverse and bill again the claim or claims that formed the basis of the appeal;
(8) when an appeal is denied, provide the challenging pharmacy and its pharmacy services administrative organization, if any, the national drug code number and supplier that has the product available for purchase in New Mexico at or below the maximum allowable cost;
(9) within one business day of granting or denying a network pharmacy's appeal, notify all network pharmacies of the decision;
(10) upon granting an appeal, allow other similarly situated network pharmacies to reverse and bill again for like claims that formed the basis of the granted appeal; and
(11) provide for each of its network pharmacy providers and the superintendent a process and mechanism to readily access the maximum allowable cost list specific to that provider.
E. A maximum allowable cost list specific to a provider and maintained by a managed care organization or pharmacy benefits manager is confidential.
F. Pursuant to Section 59A-4-3 NMSA 1978, a pharmacy benefits manager shall provide information contained in a maximum allowable cost list to the superintendent upon request by the superintendent.
History:
Laws 2014, ch. 14, § 4; 2019, ch. 269, § 3.
ANNOTATIONS
The 2019 Amendment,
effective July 1, 2019, revised the reimbursement process for generic drugs, and provided for an appeals process; in the section heading, deleted "Maximum allowable cost pricing requirements" and added "Pharmacy reimbursement practices for generic drugs; appeals process required"; added new Subsections A and B and redesignated former Subsection A as Subsection C; in Subsection C, in the introductory clause, after "pricing", deleted "shall" and added "may", deleted former paragraph designation "(1)" and redesignated former Subparagraph (a) as Paragraph C(1), deleted former subparagraph designation "(b)" and redesignated former Subparagraph (c) as Paragraph C(2), in Paragraph C(2), after "state", added "at the time of claim submission", and added new Paragraph C(3); added new subsection designation "D" and redesignated former Subsection B as Subsection E; in Subsection D, added the introductory clause, deleted former paragraph designations "(2)", "(3)" and "(4) and added new paragraph designations "(1)" through "(3)", in Paragraph D(1), after the paragraph designation, added "upon a network pharmacy's request", deleted former Paragraph (5) and added new Paragraphs D(4) through D(10) and redesignated former Paragraph (6) as Paragraph D(11); deleted former Subsection C; and added Subsection F.