2016 New Mexico Statutes
Chapter 59A - Insurance Code
Article 61 - Pharmacy Benefits Manager Regulation
Section 59A-61-4 - Maximum allowable cost pricing requirements.

59A-61-4. Maximum allowable cost pricing requirements.

A. A pharmacy benefits manager using maximum allowable cost pricing shall:

(1) to place a drug on a maximum allowable cost list, ensure that the drug:

(a) 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";

(b) has an "NR" or "NA" rating or a similar rating by a nationally recognized reference; and

(c) is generally available for purchase by pharmacies in the state from national or regional wholesalers and is not obsolete;

(2) provide to a network pharmacy provider, at the time a contract is entered into or renewed with the network pharmacy provider, the sources used to determine the maximum allowable cost pricing for the maximum allowable cost list specific to that provider;

(3) review and update maximum allowable cost price information at least once every seven business days to reflect any modification of maximum allowable cost pricing;

(4) establish a process for eliminating products from the maximum allowable cost list or modifying maximum allowable cost prices in a timely manner to remain consistent with pricing changes and product availability in the marketplace;

(5) provide a procedure under which a network pharmacy provider may challenge a listed maximum allowable cost price for a drug and respond to a challenge not later than the fifteenth day after the date the challenge is made. If the challenge is successful, a pharmacy benefits manager using maximum allowable cost pricing shall make an adjustment in the drug price effective one day after the challenge is resolved, and make the adjustment applicable to all similarly situated network pharmacy providers, as determined by the managed care organization or pharmacy benefits manager, as appropriate. If the challenge is denied, the pharmacy benefits manager using maximum allowable cost pricing shall provide the reason for the denial; and

(6) provide a process for each of its network pharmacy providers to readily access the maximum allowable cost list specific to that provider.

B. A maximum allowable cost list specific to a provider and maintained by a managed care organization or pharmacy benefits manager is confidential.

C. As used in this section, "maximum allowable cost" means the maximum amount that a pharmacy benefits manager will reimburse a pharmacy for the cost of a generic drug.

History: Laws 2014, ch. 14, 4.