Pharmacy Benefits Manager

Pharmacy Benefits Managers

Amendments to PBM Regulation Act

Amendments to the Pharmacy Benefit Managers Regulation Act, Section 59A-61-1, et seq., NMSA 1978, will go into effect July 1, 2019.  Some of the amendments are highlighted below:

Licensure
  • Licensing provisions provide for the annual renewal of license and promulgation of rules governing licensure by the SOI. 59A-61-3
  • PSAOs are required to register with the SOI. 59A-61-8
Reimbursement
  • Requires objective and verifiable sources for drug pricing. 59A-61-4(A)
  • Prohibits a PBM from paying a pharmacy less than it pays an affiliate. 59A-61-4(B)
  • Requires a PBM to disclose the derivative sources for formulating its MAC pricing for a particular provider upon request. 59A-61-4(D)(1)
  • Allows for a pharmacy to appeal reimbursement disputes directly to PBM or through its PSAO. 59A-61-4(D)(4)
  • Allows for a pharmacy to file an appeal of a PBM’s reimbursement rate appeals to be taken 21 business days after a pharmacy receives its reimbursement list. 59A-614(D)(5)(c)
  • If an appeal is successful, allows the pharmacy and similarly situated network pharmacies to resubmit claim at updated MAC price. 59A-61-4(D)(7) and (10)
  • If a PBM does not respond to an appeal on MAC list reimbursement pricing within 14 business days it is granted by default. 59A-61-4(6)
  • Requires PBM to provide access to the MAC list to the superintendent and all network pharmacies. 59A-61-4(D)(11)
Contracts
  • Prohibits gag orders on pharmacists informing patients about lower cost options. 59A-615(E)(3)
  • Prohibits recoupment resulting from low sales of certain drugs or non-compliance by patients (scores and metrics or both). 59A-61-5(F)
  • Requires a PBM to provide specific documentation to a pharmacy or the superintendent within 7 days upon request. 59A-61-5(G)
  • Prohibits PBMs from charging a fee for a service unless it is itemized in a contract between a PBM and a pharmacy. 59A-61-7(B)
General
  • A PBM shall submit a network adequacy report. 59A-61-5(H)
  • Allows the superintendent to examine PBM records to determine compliance. 59A-61-5(I)
Audit
  • Requires a PBM to be subject to Section 61-11-18.2 NMSA 1978. (See below.) AMENDMENT TO 61-11-18.2: AUDITS OF PHARMACIES

 Amendments to Section 61-11-18.2 NMSA 1978 went into effect on June 14, 2019.  Some of the updates include:

  •  Provides a minimum of two weeks’ notice to pharmacy of on-site audit 61-11-18.2(A)(1)
  • Allows at least 21 business days for a pharmacy to respond to a preliminary audit report to address discrepancies 61-11-18.2(A)(7)
  • Maximum of two year audit period from date of claim submitted or adjudicated 61-11-2(A)(8)
  • Scheduling prohibition of audit initiation during first five days of the month 61-11-2(A)(9)
  • Prohibits extrapolation in calculating recoupments or penalties 61-11-18.2(A)(11)
  • Prohibits compensation to an auditing entity based on recoupments or penalties 61-11-2(A)(12)
  • Prohibits charging pharmacies a fee for conducting an on-site or desk audit unless there is a finding of actual fraud 61-11-18.2(A)(13)
  • Allows a pharmacy to correct a clerical or recordkeeping error and resubmit the claim 6111-18.2(A)(14)
  • Prohibits requiring valid prescription standards that are more stringent than federal or state requirements 61-11-18.2(A)(15)
  • Prohibits recoupment for prescriptions on commercially available package sizes exceeding entity’s maximum days’ supply requirement 61-11-18.2(A)(18)
  • Prohibits recoupment for prescription refills on commercially available package sizes exceeding entity’s maximum days’ supply requirement 61-11-18.2(A)(19)
  • Prohibits recoupment on uncollected co-pays with documentation of pharmacy’s reasonable attempt to collect 61-11-18.2(A)(20)
  • Prohibits recoupments until final conclusion of audit 61-11-18.2(B)
  • Defines entity for applicability purposes 61-11-18.2(F)(1)
  • Defines extrapolation 61-11-18.2(F)(2)

 

 

To access the PBM Regulation Act, click here

To access Auditing of Pharmacy Records statute, click here

To file a complaint against a PBM with the Office of Superintendent of Insurance, click here