N.M. Code R. § 8.308.9.14 - PHARMACY SERVICES

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.

J. The MCO shall meet all federal and state requirements for identifying drug items purchased under the 340B drug purchasing provisions codified as Section 340B of the federal Public Health Service Act.

Notes

N.M. Code R. § 8.308.9.14

8.308.9.14 NMAC - N, 1-1-14, Adopted by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018