N.M. Stat. § 27-2-12.34

Current through 2024, ch. 69

Section 27-2-12.34 - Community-based pharmacy reimbursement

A. Each managed care organization that contracts with the department shall ensure that community-based pharmacy providers that provide services to medicaid recipients are reimbursed as follows:

(1) for the ingredient cost of a drug at a value that is at least equal to the national average drug acquisition cost for the prescription drug at the time that the drug is administered or dispensed, or if data for the national average drug acquisition is unavailable, the wholesale acquisition cost of the drug; and

(2) a professional dispensing fee.

B. The professional dispensing fee reimbursed to community-based pharmacy providers shall be no less than the professional dispensing fee reimbursed to community-based pharmacy providers for covered outpatient drugs in the medicaid fee-for-service program.

C. By January 1, 2025, and annually thereafter, the department shall compile a list of all community-based pharmacy providers in the state and publish the list on the department's website.

D. For the purposes of this section:

(1) "community-based pharmacy provider" means a pharmacy that is:

(a) open to the public for prescriptions to be filled, regardless of the facility or practice where the prescription was written;

(b) located in the state or near the state border, if the border town is a primary source of prescription drugs for medicaid recipients residing in the border area; and

(c) not:

1) government-owned;

2) hospital-owned;

3) owned by a corporation that owns hospitals;

4) an extension of a medical practice or special facility;

5) owned by a corporate chain of pharmacies with stores outside of the state; or

6) a mail-order pharmacy;

(2) "ingredient cost" means the actual amount paid to a community-based pharmacy provider for a prescription drug, not including the professional dispensing fee or cost sharing;

(3) "managed care organization" means a person or entity eligible to enter into risk-based prepaid capitation agreements with the department to provide health care and related services;

(4) "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;

(5) "medicaid recipient" means a person whom the department has determined to be eligible to receive medicaid-related services;

(6) "national average drug acquisition cost" means the national average of prices at which pharmacies purchase a prescription drug from manufacturers or wholesalers; and

(7) "wholesale acquisition cost" means a manufacturer's list price for a prescription drug sold to wholesalers in the United States, not including discounts, rebates or reductions in price.

NMS § 27-2-12.34

Added by 2024, c. 35,s. 1, eff. 7/1/2024.