1. A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, a rare disease or condition, a serious mental illness 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 three business days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could:

   1. (1) seriously jeopardize a covered person's life or overall health;
   2. (2) affect a covered person's ability to regain maximum function; or
   3. (3) subject a covered person to severe and intolerable pain.

2. B. A health insurer or pharmacy benefits manager 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, a serious mental illness 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. Prior authorization or step therapy requirements may be used when necessary for the clinical safety of a person with a serious mental illness if the person is:

   1. (1) younger than eighteen years of age; or
   2. (2) residing in an institutionalized setting.

3. C. A health insurer or pharmacy benefits manager 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 three business days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could:

   1. (1) seriously jeopardize a covered person's life or overall health;
   2. (2) affect a covered person's ability to regain maximum function; or
   3. (3) subject a covered person to severe and intolerable pain.

4. D. After a health insurer or pharmacy benefits manager approves prior authorization for a chronic maintenance drug, the health insurer or pharmacy benefits manager shall not require subsequent prior authorization more than once every three years, unless:

   1. (1) the prior authorization was obtained based on fraud or misrepresentation;

   2. (2) final action by the federal food and drug administration, other regulatory agencies or the drug manufacturer:

      1. (a) removes the chronic maintenance drug from the market;
      2. (b) limits use of the chronic maintenance drug in a manner that affects the prior authorization; or
      3. (c) communicates a patient safety issue that would affect the prior authorization;
   3. (3) a generic equivalent or drug that is biosimilar to the chronic maintenance drug is added to the health insurer's or pharmacy benefits manager's drug formulary; or
   4. (4) the prescription is written for drugs that may have a cosmetic use, including weight loss medications.

History: Laws 2023, ch. 114, § 13; 2024, ch. 42, § 4; 2025, ch. 57, § 3; 2026, ch. 47, § 4.

ANNOTATIONS

The 2026 amendment, effective May 20, 2026, included "serious mental illness" to the list of conditions for which prior authorization for prescription drugs or step therapy is prohibited, reduced the time from seven days to three business days within which medical necessity determinations will be automatically approved under certain circumstances, and included pharmacy benefits managers within the scope of the section; in Subsection A, in the introductory paragraph, after "rare disease or condition" added "a serious mental illness", and after "approved within" deleted "seven" and added "three business"; in Subsection B, after "health insurer" added "or pharmacy benefits manager", after "cancer" added "a serious mental illness", and after "generic version is available", added "Prior authorization or step therapy requirements may be used when necessary for the clinical safety of a person with a serious mental illness if the person is", and added Paragraphs B(1) and B(2); in Subsection C, after "health insurer" added "or pharmacy benefits manager", after "approved within", deleted "seven" and added "three business"; and added Subsection D.

Applicability. — Laws 2026, ch. 47, § 5 provided that the provisions of Laws 2026, ch. 47 apply to an individual or group policy, contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer or pharmacy benefits manager on or after January 1, 2027, pursuant to any of the following:

A. Chapter 59A, Article 22 NMSA 1978;

B. Chapter 59A, Article 23 NMSA 1978;

C. the Health Maintenance Organization Law [Chapter 59A, Article 46 NMSA 1978];

D. the Nonprofit Health Care Plan Law [Chapter 59A, Article 47 NMSA 1978]; or

E. the Health Care Purchasing Act [Chapter 13, Article 7 NMSA 1978].

Laws 2025, ch. 57, § 4 provided that the provisions of Laws 2025, ch. 57, apply to an individual or group policy, contract, certificate or agreement to provide, deliver, arrange for, pay for or reimburse any of the costs of medical care, pharmaceutical benefits or related benefits that is entered into, offered or issued by a health insurer on or after July 1, 2025, pursuant to any of the following:

A. Chapter 59A, Article 22 NMSA 1978;

B. Chapter 59A, Article 23 NMSA 1978;

C. the Health Maintenance Organization Law [Chapter 59A, Article 46 NMSA 1978];

D. the Nonprofit Health Care Plan Law [Chapter 59A, Article 47 NMSA 1978]; or

E. the Health Care Purchasing Act [Chapter 13, Article 7 NMSA 1978].

Laws 2024, ch. 42, § 7 provided that the provisions of Sections 1 and 3 through 6 [13-7-18, 59A-22-53.1, 59A-22B-8, 59A-46-52.1, 59A-47-47.1 NMSA 1978] of this act do not apply to short-term plans subject to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978].

Laws 2024, ch. 42, § 8 provided that the provisions of Laws 2024, ch. 42 apply to group health insurance policies, health care plans or certificates of health insurance, other than small group health plans, that are delivered, issued for delivery or renewed in this state on or after January 1, 2025.

The 2025 amendment, effective June 20, 2025, added more classes of drugs that are not subject to prior authorizations or step therapy protocols; in Subsection A, in the introductory paragraph, after "cancer" added "rare diseases or condition", after "medical necessity determination" added "made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review", and after "generic version is available", added the remainder of the subsection, and added Paragraphs A(1) through A(3); in Subsection B, after "medical necessity determination" added "made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review"; and added Subsection C.

The 2024 amendment, effective May 15, 2024, added autoimmune disorders and cancer to an existing provision for which prior authorization for certain prescription drugs is not required, except in cases in which a biosimilar, interchangeable biologic or a generic version is available, and added autoimmune disorder and cancer to an existing provision for which step therapy requirements shall not be imposed, except in cases in which a biosimilar, interchangeable biologic or generic version is available; in Subsection A, after "for the treatment of", added "an autoimmune disorder, cancer or", and added "biosimilar, interchangeable biologic or" preceding "generic"; and in Subsection B, after "for the treatment of", added "an autoimmune disorder, cancer or", and added "biosimilar, interchangeable biologic or" preceding "generic".