On Feb. 13, NM LEG reported bill on step therapy guidelines.
NM LEG issued bill SB 135 to modify guidelines relating to step therapy (ST) for prescription drug coverage and eliminate requirements for certain conditions.
Would amend Health Care Purchasing Act, Public Assistance Act, other statutes.
To regulate process used by insurers to require patients/prescribers to use preferred or less expensive medications before graduating to expensive/non-preferred medications.
Applies same requirements to all forms of health insurance available in New Mexico.
Bill Provisions
Bill amends NM LEG 13-7-18 to require step therapy protocols established with clinical review criteria; plan must have clear process to request exception to ST.
Plan must grant exception if prescribing provider demonstrates drug is contraindicated.
Must grant exception if provider demonstrates drug will cause adverse reaction; if drug is expected to be ineffective; if patient tried, failed drug or a drug in the same class.
Must provide exception in case when drug is not in the best interest of the patient.
Once an exception is granted, requires the plan authorize coverage for life of enrollee.
Under current rule, there is a 130-day time period for exceptions; if drug is not filled within 130 days of exception being granted it is considered discontinuation of therapy.
Plan must respond to exception request in 72 hours (24 hours in emergency); required to grant exception if no timely response; must authorize coverage pending decision.
Prohibited prior authorization or ST for drugs that treat autoimmune disorders, behavioral health, cancer; currently prohibited for substance use disorder treatment.
Red line tracked changes begin on page 5 of the bill updated as of Feb. 7, 2024.
Legislative History
On Jan. 22, 2024, bill was introduced in Senate; on Feb. 8, 2024, bill passed Senate.
On Feb. 8, 2024, bill was introduced in House; on Feb. 13, 2024, bill passed House.
Effectiveness
NM LEG Bill SB 135 becomes effective for policies, plans beginning Jan. 1, 2025.
Mar. 2024 NM LEG Bill Approval
On Mar. 1, 2024, NM LEG reported governor signed bill into law, assigned Chapter 42.
Regulators
NM LEG
Entity Types
Ins
Reference
Ch. 42, 3/4/2024; Bill SB135, 3/1/2024; Bill SB135, 2/13/2024; Citation: NM LEG 13-7-18;
