Committee Substitute for HB0192BI1

HOUSE BUSINESS AND INDUSTRY COMMITTEE SUBSTITUTE FOR

HOUSE BILL 192

49th legislature - STATE OF NEW MEXICO - first session, 2009

AN ACT

RELATING TO PRESCRIPTION DRUGS; REQUIRING THAT INSURERS AND HEALTH MAINTENANCE ORGANIZATIONS PERMIT LICENSED PHARMACISTS TO INITIATE THE PRIOR AUTHORIZATION PROCESS WHEN SEEKING TO FILL PRESCRIPTIONS FOR MEDICALLY FRAGILE INDIVIDUALS; MANDATING INSURERS TO COMPLY WITH TRANSPARENCY MEASURES; ENACTING SECTIONS OF THE NMSA 1978.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

Section 1. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] REQUIREMENT FOR REIMBURSEMENT WHERE PHARMACISTS INITIATE PRIOR AUTHORIZATION FOR MEDICALLY FRAGILE INDIVIDUALS.--

A. An individual or a group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in New Mexico that requires covered individuals to obtain prior authorization before making reimbursement for a prescription shall permit a participating pharmacist licensed pursuant to the Pharmacy Act to initiate the prior authorization process when seeking to fill a prescription for a medically fragile individual.

B. An insurer shall notify a person requesting prior authorization on behalf of a medically fragile covered individual of its determination regarding the prior authorization as expeditiously as the covered individual's health condition requires, but no later than two business days after the insurer receives all information that it reasonably requires in instances where the request indicates that the approval is necessary to protect a medically fragile individual's health.

C. Prior authorization request information regarding the procedure for submission and determination of prior authorization requests shall be prominently available on the insurer's web site and available to prescribers and pharmacists upon request in written form.

D. As used in this section, "medically fragile" means having a health status deemed to be medically fragile by agreement between a practitioner and the individual's insurer."

Section 2. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] AVAILABILITY OF FORMULARY AND PRIOR AUTHORIZATION INFORMATION.--An insurer that limits covered drugs to those listed on a formulary shall make information about each plan's formulary and prior authorization procedure available prominently on its web site and, by request, in writing. Information about the plan's formulary made available pursuant to this section shall include:

A. the manner in which the formulary functions, including any tiered cost-sharing structure and utilization management procedures;

B. the process for obtaining an exception to a plan's formulary or tiered cost-sharing structure;

C. a description of how a covered individual may obtain additional information regarding the formulary;

D. information regarding the pharmacies from which a covered individual may obtain drugs covered by the insurer; and

E. information regarding how covered individuals may obtain drugs at out-of-network pharmacies."

Section 3. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PRESCRIPTION DRUG COVERAGE GRIEVANCES, COVERAGE DETERMINATIONS AND APPEALS PROCEDURES.--

A. All grievances, coverage determinations, reconsiderations, exceptions and appeal rights and procedures available to covered individuals shall be prominently displayed on the plan's web site and provided in writing to insured individuals upon policy issuance and renewal. This information shall be provided to all pharmacies accepting reimbursement from an insurer, and pharmacies shall provide this information to a covered person in oral or written form whenever an adverse coverage determination is made.

B. For the purposes of this section:

(1) "adverse coverage determination" means an insurer's coverage determination for a prescription drug in which it determines that coverage for the drug is denied or reduced, subject to a condition precedent, or terminated; and

(2) "coverage determination" means an insurer's decision as to whether or not it will pay for a prescription drug for a covered individual, or whether coverage for the drug will be subject to a condition precedent." Section 4. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] REQUIREMENT FOR REIMBURSEMENT WHERE PHARMACISTS INITIATE PRIOR AUTHORIZATION FOR MEDICALLY FRAGILE INDIVIDUALS.--

A. A blanket or group health insurance policy or contract that is delivered, issued for delivery or renewed in New Mexico that requires covered individuals to obtain prior authorization before making reimbursement for a prescription shall permit any participating pharmacist licensed pursuant to the Pharmacy Act to initiate the prior authorization process when seeking to fill a prescription for a medically fragile individual.

B. An insurer shall notify a person requesting prior authorization on behalf of a medically fragile covered individual of its determination regarding the prior authorization as expeditiously as the insured individual's health condition requires, but no later than two business days after the insurer receives all information that it reasonably requires in instances where the request indicates that the approval is necessary to protect a medically fragile individual's health.

D. As used in this section, "medically fragile" means having a health status deemed to be medically fragile by agreement between a practitioner and the individual's insurer."

Section 5. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

A. the manner in which the formulary functions, including any tiered cost-sharing structure and utilization management procedures;

B. the process for obtaining an exception to a plan's formulary or tiered cost-sharing structure;

C. a description of how a covered individual may obtain additional information regarding the formulary;

D. information regarding the pharmacies from which a covered individual may obtain drugs covered by the insurer; and

E. information regarding how insured persons may obtain drugs at out-of-network pharmacies."

Section 6. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PRESCRIPTION DRUG COVERAGE GRIEVANCES, COVERAGE DETERMINATIONS AND APPEALS PROCEDURES.--

A. All grievances, reconsiderations, exceptions, coverage determinations and appeal rights and procedures available to insured persons shall be prominently displayed on the plan's web site and provided in writing to insured individuals upon policy issuance and renewal. This information shall be provided to all pharmacies accepting reimbursement from an insurer, and pharmacies shall provide this information to a covered individual in oral or written form whenever an adverse coverage determination is made.

B. For the purposes of this section:

Section 7. A new section of Chapter 59A, Article 46 NMSA 1978 is enacted to read:

"[NEW MATERIAL] REQUIREMENT FOR REIMBURSEMENT WHERE PHARMACISTS INITIATE PRIOR AUTHORIZATION FOR MEDICALLY FRAGILE INDIVIDUALS.--

A. An individual or group health maintenance contract that is delivered, issued for delivery or renewed in New Mexico that requires covered individuals to obtain prior authorization before making reimbursement for a prescription shall permit a participating pharmacist licensed pursuant to the Pharmacy Act to initiate the prior authorization process when seeking to fill a prescription for a medically fragile individual.

B. A health maintenance organization shall notify a person requesting prior authorization on behalf of a medically fragile covered individual of its determination regarding the prior authorization as expeditiously as the covered individual's health condition requires, but no later than two business days after the health maintenance organization receives all information that it reasonably requires in instances where the request indicates that the approval is necessary to protect a medically fragile individual's health.

C. Prior authorization request information regarding the procedure for submission and determination of prior authorization requests shall be prominently available on the health maintenance organization's web site and available to prescribers and pharmacists upon request in written form.

D. As used in this section, "medically fragile" means having a health status deemed to be medically fragile by agreement between a practitioner and the individual's insurer."

Section 8. A new section of Chapter 59A, Article 46 NMSA 1978 is enacted to read:

"[NEW MATERIAL] AVAILABILITY OF FORMULARY AND PRIOR AUTHORIZATION INFORMATION.--A health maintenance organization that limits covered drugs to those listed on a formulary shall make information about each plan's formulary and prior authorization procedure available prominently on its web site and, by request, in writing. Information about the plan's formulary made available pursuant to this section shall include:

A. the manner in which the formulary functions, including any tiered cost-sharing structure and utilization management procedures;

B. the process for obtaining an exception to a plan's formulary or tiered cost-sharing structure;

C. a description of how a covered individual may obtain additional information regarding the formulary;

D. information regarding the pharmacies from which a covered individual may obtain drugs covered by the health maintenance organization; and

E. information regarding how covered individuals may obtain drugs at out-of-network pharmacies."

Section 9. A new section of Chapter 59A, Article 46 NMSA 1978 is enacted to read:

"[NEW MATERIAL] PRESCRIPTION DRUG COVERAGE GRIEVANCES, COVERAGE DETERMINATIONS AND APPEALS PROCEDURES.--

A. All grievances, coverage determinations, reconsideration, exceptions and appeal rights and procedures available to covered individuals shall be prominently displayed on the plan's web site and provided in writing to insured individuals upon policy issuance and renewal. This information shall be provided to all pharmacies accepting reimbursement from a health maintenance organization, and pharmacies shall provide this information to a covered individual in oral or written form whenever an adverse coverage determination is made.

B. For the purposes of this section:

(1) "adverse coverage determination" means a health maintenance organization's coverage determination for a prescription drug where it determines that coverage for the drug is denied or reduced, subject to a condition precedent, or terminated; and

(2) "coverage determination" means a health maintenance organization's decision as to whether or not it will pay for a prescription drug for a covered individual, or whether coverage for the drug will be subject to a condition precedent."

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