New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 9 - BENEFIT PACKAGE › Section 8.308.9.14 - PHARMACY SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The benefit package includes pharmacy and related services,
				  as detailed in 8.324.4 NMAC.
A. The
				MCO may determine its formula for estimating acquisition cost and establishing
				pharmacy reimbursement.
B. The MCO
				shall include on the MCO's formulary or PDL all multi-source generic drug items
				with the exception of items used for cosmetic purposes, items consisting of
				more than one therapeutic ingredient, anti-obesity items, items that are not
				medically necessary and as otherwise approved by MAD. Cough, cold and allergy
				medications must be covered but all multi-source generic products do not need
				to be covered. This requirement does not preclude a MCO from requiring
				authorization prior to dispensing a multi-source generic item.
C. The MCO is not required to cover all
				multi-source generic over-the-counter items. Coverage of over-the-counter items
				may be restricted to instances for which a practitioner has written a
				prescription, and for which the item is an economical or preferred therapeutic
				alternative to the prescribed item.
D. The MCO shall cover brand name drugs and
				drug items not generally on the MCO formulary or PDL when determined to be
				medically necessary by the MCO or as determined by the MCO member appeal
				process or a HSD administrative hearing. See 8.308.15 NMAC.
E. Unless otherwise approved by MAD, the MCO
				shall have an open formulary for all psychotropic medications. Minor
				tranquilizers, sedatives, and hypnotics are not considered psychotropic
				medications for the purpose of this rule.
F. MCO shall ensure that a native American
				member accessing the pharmacy benefit at an Indian health service (IHS),
				tribal, and urban Indian (I/T/U) facility is exempt from the MCO's PDL when
				these pharmacies have their own PDL.
G. The MCO shall reimburse family planning
				clinics, school-based health centers (SBHCs) and the department of health (DOH)
				public health clinics for oral contraceptive agents and plan B when dispensed
				to a member and billed using healthcare common procedure coding (HCPC) codes
				and CMS 1500 forms.
H. The MCO
				shall meet all federal and state requirements related to pharmacy rebates and
				submit all necessary information as directed by HSD.
I. For a member 21 years of age and older not
				residing in an institution, the MCO must, at a minimum , cover the
				over-the-counter items which are insulin
,
diabetic test strips,
				prenatal vitamins, electrolyte replacement items, ophthalmic lubricants,
				pediculosides and scabicides, certain insect repellants, sodium chloride for
				inhalations, topical and vaginal antifungals and topical anti-inflammatories.
				Other over-the-counter items may be designated as covered items after making a
				specific determination that it is overall more economical to cover an
				over-the-counter item as an alternative to prescription items or when an
				over-the-counter item is a preferred therapeutic alternative to prescription
				drug items. Such coverage is subject to the generic-first coverage provisions.
				Otherwise, the eligible recipient 21 years and older, or his or her authorized
				representative is responsible for purchasing or otherwise obtaining an
				over-the-counter item.
(1) The MCO may cover
				additional over-the counter items, with or without prior authorization, at its
				discretion or as medically necessary when a specific regimen of
				over-the-counter drugs is required to treat chronic disease
				conditions.
(2) For a member under
				21 years of age, the MCO must cover over-the-counter drug items as medically
				necessary for the member, with or without prior authorization.