Pharmacy Benefits Manager

Pharmacy Benefits Managers

Pharmacy Benefits Manager definition:

59A-61-2.H NMSA 1978
“Pharmacy Benefits Manager” means a person or a wholly or partially owned or controlled subsidiary of a person that provides claims administration, benefit design and management, pharmacy network management, negotiation and administration of product discounts, rebates and other benefits accruing to the pharmacy benefits manager or other prescription drug or device services to third parties, but “pharmacy benefits manager” does not include licensed health care facilities, pharmacies, licensed health care professionals, health insurers, unions, health maintenance organizations, Medicare advantage plans or prescription drug plans when providing formulary services to their own patients, employees, members or beneficiaries;

License requirements

59A-61-3 NMSA 1978
A person shall not operate as a pharmacy benefits manager unless licensed by the superintendent in accordance with the Pharmacy Benefits Manager Regulation Act and applicable federal and state laws.

Pharmacy Benefit Managers Compliance Guidance

Pharmacy Benefit Managers (PBMs) operating in the state of New Mexico are regulated under the Pharmacy Benefit Manager Regulation Act, Sections 59A-61-1 – 59A-61-7, NMSA 1978.

Compliance Specifics
  • PBM is required to obtain and maintain licensure with the Office of the Superintendent of Insurance (OSI). (59A-61-3, NMSA 1978)
  • PBM required to ensure that a drug placed on a Maximum Allowable Cost (MAC) list is listed “A” or “B” rated in the “orange book” to its therapeutic equivalent(s). (59A-61-4, NMSA 1978)
  • PBM is required to ensure that a drug placed on a MAC list is generally available for purchase in the state and is not obsolete (59A-61-4, NMSA 1978)
  • PBM is required to provide network pharmacy provider the sources used to determine the MAC pricing for the MAC list specific to each provider upon entering or renewing a contract. (59A-61-4, NMSA 1978)
  • PBM required to review and update MAC price information at least once every seven business days to reflect any modification to MAC pricing. (59A-61-4, NMSA 1978)
  • PBM is required to establish a process for eliminating products from a MAC list or modifying a MAC list in a timely manner to remain consistent with price changes and availability in the marketplace. (59A-61-4, NMSA 1978)
  • PBM is required to provide a procedure under which a network pharmacy provider may challenge a MAC price for a drug. (59A-61-4, NMSA 1978)
  • PBM is required to respond to a challenged MAC price within 15 days from the date the challenge was made (59A-61-4, NMSA 1978)
  • PBM is required to make an adjustment in the drug price effective one day after a successful challenge is resolved, applicable to all similarly situated network pharmacy providers. (NM HB 126 Section 4.A(5) / Section 59A-61-4, NMSA 1978)
  • PBM is required to provide a reason for denial for an unsuccessful MAC price challenge. (59A-61-4, NMSA 1978)
  • PBM is required to provide a process for a network pharmacy provider to readily access the MAC list specific to that provider. (59A-61-4, NMSA 1978)
  • PBM shall not require that a pharmacy participate in one contract in order to participate in another contract. (59A-61-5, NMSA 1978)
  • PBM shall provide a contract written in plain English to pharmacy provider at least thirty days prior to its execution. (59A-61-5, NMSA 1978)
  • PBM is required to comply with Section 61-11-18.2 NMSA 1978 regarding an audit. (59A-61-6, NMSA 1978 and 61-11-18.2 NMSA 1978)
  • PBM is prohibited from charging a pharmacist or pharmacy a fee related to the adjudication of a claim, including:
    • the receipt and processing of a pharmacy claim;
    • the development or management of a claim processing or adjudication network; or
    • participation in a claim processing or claim adjudication network. (59A-61-7, NMSA 1978)
Phone: 1-855-4ASK-OSI (1-855-427-5674)
1120 Paseo de Peralta, Suite 428
Santa Fe, NM 87501