This text of New Mexico § 59A-22B-8 (Prior authorization for prescription drugs or step) is published on Counsel Stack Legal Research, covering New Mexico primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
therapy for certain conditions prohibited. A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, rare disease or condition or a substance use disorder, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, shall not be subject to prior authorization, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Medical necessity determinations shall be automatically approved within seven days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could:
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therapy for certain conditions prohibited. A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, rare disease or condition or a substance use disorder, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, shall not be subject to prior authorization, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Medical necessity determinations shall be automatically approved within seven days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could: (1) seriously jeopardize a covered person's life or overall health; (2) affect a covered person's ability to regain maximum function; or (3) subject a covered person to severe and intolerable pain. B. A health insurer shall not impose step therapy requirements before authorizing coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer or a substance use disorder, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, except in cases in which a biosimilar, interchangeable biologic or generic version is available. C. A health insurer shall not impose step therapy requirements before authorizing coverage for an off-label medication that is prescribed for the treatment of a rare disease or condition, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Medical necessity determinations shall be automatically approved within seven days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could: (1) seriously jeopardize a covered person's life or overall health; (2) affect a covered person's ability to regain maximum function; or (3) subject a covered person to severe and intolerable pain.