Regulations & Compliance 

New Mexico Board of Pharmacy
Access licensing, applications, rules, and regulatory updates directly from the Board.
https://www.rld.nm.gov/boards-and-commissions/individual-boards-and-commissions/pharmacy/

Pharmacy Benefits Manager Regulation (59A-61)
New Mexico statute governing PBM practices and requirements.
https://nmonesource.com/nmos/nmsa/en/item/4376/index.do#!fragment//BQCwhgziBcwMYgK4DsDWMCWEg7O8CyA3gLABQCCAFgJQCuAtgE7IA0iaJgHICqA7AEwCWAdgHYAeSgBG0ANgEMAbmABYB7EADgAsASgCUi+AJQAiAQQAWRQCuAJV4A0JYAc0IBnYUBZACJ4AviA

Audit of Pharmacy Records (61-11-18.2)
Statute outlining requirements and protections related to pharmacy audits.
https://nmonesource.com/nmos/nmsa/en/item/4416/index.do#!fragment//BQCwhgziBcwMYgK4DsDWMCWEg7O8CyA3gLABQCCAFgJQCuAtgE7IA0iaJgHICqA7AEwCWAdgHYAeSgBG0ANgEMAbmABYB7EADgAsASgCUi+AJQAiAQQAWRQCuAJV4A0JYAc0IBnYUBZACJ4AviA

Prompt Payment Requirements (59A)
New Mexico law requires timely reimbursement of pharmacy claims, including updated clean claim requirements.

Billing & Reimbursement

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Medicaid Community Pharmacy list - updated July 2, 2023

Click here to see the list of Community Based Pharmacies through the NM Medicaid Program! FYI - Medicaid wants to make sure all independent community pharmacy providers for NM patients, in New Mexico and surrounding states, are included in their list.

Reimbursement by Medicaid MCO's for Pharmacist Clinical Services as required by HB 42 - 7/15/2022

Blue Cross Blue Shield - Prime Therapeutics

Presbyterian - OptumRx

Western Sky Community Care - CVS Caremark - updated document 8/8/22

Western Sky Community Care created - special instructions just for Vaccines for HB42

document - posted 11/16/22

Medicaid Supplement issued March 2022 regarding reimbursement for Pharmacists clinical services (HB 42 implementation)

Superintendent of Insurance information This is a bulleting from our Superintendent regarding the requirement for health plans to comply with the pharmacists reimbursement parity law (HB 42).

CMS Information Update: New information September 27, 2018

How Medicare Drug Plans Use Pharmacies, Formularies, & Common Coverage Rules

Finding NADAC pricing information:

The NADAC (and the ACA FUL) are found on the links on the following website:

https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html

You enter the NDC code in the search function once you have gone to the time period you want.  It seems to work well.

Pharmacy Benefits Manager Regulation 59A-61

Click here to see the statute

Audit of pharmacy records 61-11-18.2.

Click here to see the statute

Pharmacies billing Medicaid when providing vaccinations!

Xerox has  implemented this in the system, so pharmacies can now bill Medicaid for vaccine  administration.

Click here to see the updated payer sheet

with instructions on how  to bill for vaccine administration (see segments 438-E3 and 440-E5).

There is no specific limitation on the vaccines eligible for the administration fee. Vaccine administration may be billed for any vaccine that the pharmacist is certified to administer and that is covered under the Medicaid recipient’s category of eligibility.

It is important to note that only one vaccine administration fee is allowed for each “poke” regardless of how many components are in the vaccine.

There are two Supplements on the topic available at:

http://www.hsd.state.nm.us/mad/pdf_files/Registers/Registers2013/1301%20Primary%20Care%20Increase%20Revised%20Feb%202013.pdf

and

http://www.hsd.state.nm.us/mad/pdf_files/Registers/Registers2013/1303%20Primary%20Care%20Increase%20Feb%202013.pdf

59A-Prompt Payment requirements

During the 2021 Legislative Session, the prompt pay/clean claims requirement for pharmacy reimbursement was modified to require payment within 15 days of the pharmacy filing a prescription drug claim with a health plan or PBM. We hope to get the appropriate document on line in this location soon.

Billing Medicaid for OTC Emergency Contraception

Link to the Medicaid Supplement authorizing OTC billing - click here

Link to payment flow chart and billing mechanism

Two New Electronic Prescribing Section Pages Now Available 

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that two (2) new section pages have been created on the 2009 Electronic Prescribing (E-Prescribing) Incentive Program web page on the CMS website.

E-Prescribing Measure Section page - This page contains several resources including: Measure Specifications; new Claims-Based Reporting Principles and a Sample E-Prescribing Claim.   To access these resources, visit http://www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp on the CMS website.  

Educational Resources Section Page – This page contains MLN Matters articles; E-Prescribing Incentive Program fact sheets; a link to Medicare’s Practical Guide to the E-Prescribing Incentive Program, and information on how to receive continuing education credit related to the E-Prescribing Incentive Program. To access these resources and information, visit http://www.cms.hhs.gov/ERxIncentive/09_Educational_Resources.asp on the CMS website. 

New and updated information will continually be added, so please visit the E-Prescribing Incentive Program web page at http://www.cms.hhs.gov/ERXIncentive on the CMS website on a frequent basis.

CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA)

Linked below are documents from the CDC that discusses best practices for CLIA waived testing that is very helpful and describes proper policies and procedures for anyone wanting to provide testing.

It is highly recommend that any pharmacy that provides CLIA waived testing develop a policy and procedures manual so that proper testing can be performed for each patient.  The policy and procedures manual needs to include procedures for each test and should include documentation of quality control (testing of new lots of test cassettes or reagents, testing the device, documenting proper storage, etc).

Q & A:

Answers from Joe Anderson at UNM College of Pharmacy.

How difficult is it to get a CLIA Waiver?  

It is not hard at all.  Those interested should contact the New Mexico Department of Health for specific information.  A power point slide show is linked below that I think will help folks to understand better.

Do you have to register the pharmacy as a lab?

You can register as a pharmacy or as a lab or several other categories (see slide show).  A Pharmacy should register as a mobile laboratory if you plan to do screenings at a variety of locations.

What does a CLIA waiver allow you to do?  

It allows you to offer laboratory testing to patients for tests that are CLIA-waived.  Click the link for a list of CLIA-Waived tests.

Slide Show - How to obtain a waiver

Morbidity and Mortality Weekly Report - Good Laboratory Practices for Waived Testing Sites

Application for CLIA Waiver Certification

Tests Granted Waived Status under CLIA

Billing & Reimbursement