As used in the Pharmacy Benefits Manager Regulation Act:

1. A. "maximum allowable cost" means the maximum amount that a pharmacy benefits manager will reimburse a pharmacy for the cost of a generic drug;
2. B. "maximum allowable cost list" means a searchable, electronic and internet-based listing of drugs used by a pharmacy benefits manager setting the maximum allowable cost on which reimbursement to a pharmacy or pharmacist is made;
3. C. "obsolete" means a product that is listed in national drug pricing compendia but is no longer available to be dispensed based on the expiration date of the last lot manufactured;
4. D. "pharmacist" means an individual licensed as a pharmacist by the board of pharmacy;
5. E. "pharmacy" means a licensed place of business where drugs are compounded or dispensed and pharmacist services are provided;

6. F. "pharmacy benefits management" means a service provided to or conducted by a health plan as defined in Section 59A-16-21.1 NMSA 1978 or health insurer that involves:

   1. (1) prescription drug claim administration;
   2. (2) pharmacy network management;
   3. (3) negotiation and administration of prescription drug discounts, rebates and other benefits;
   4. (4) design, administration or management of prescription drug benefits;
   5. (5) formulary management;
   6. (6) payment of claims to pharmacies for dispensing prescription drugs;
   7. (7) negotiation or administration of contracts relating to pharmacy operations or prescription benefits; or
   8. (8) any other service determined by the superintendent as specified by rule to be a pharmacy benefits management activity;
7. G. "pharmacy benefits manager" means an entity that provides pharmacy benefits management services;
8. H. "pharmacy benefits manager affiliate" means a pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls, is owned or controlled by or is under common ownership or control with a pharmacy benefits manager;
9. I. "pharmacy services administrative organization" means an entity that contracts with a pharmacy or pharmacist to act as the pharmacy or pharmacist's agent with respect to matters involving a pharmacy benefits manager or third-party payor, including negotiating, executing or administering contracts with the pharmacy benefits manager or third-party payor; and
10. J. "superintendent" means the superintendent of insurance.

History: Laws 2014, ch. 14, § 2; 2019, ch. 269, § 1.

ANNOTATIONS

Cross references. — For the Employee Retirement Income Security Act of 1974, see 29 U.S.C. §§ 1001 through 1453.

For Part C of Title 18 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, see 42 U.S.C. §§ 902(a)(5), 1395w-101, 1395w-114 and -115.

The 2019 amendment, effective July 1, 2019, defined "maximum allowable cost", "maximum allowable cost list", "obsolete", "pharmacy benefits manager affiliate" and "pharmacy services administrative organization", and revised and removed the definitions of certain terms as used in the Pharmacy Benefits Manager Regulation Act; deleted former Subsections A through C, which defined "covered entity", "covered individual" and "medicare advantage plan", respectively, and added new Subsections A through C; in Subsection F, in the introductory clause, deleted "the service provided to a health benefit plan or health insurer, directly or through another person, including the procurement of prescription drugs to be dispensed to patients, or the administration or management of prescription drug benefits, including" and added "a service provided to or conducted by a health plan as defined in Section 59A-16-21.1 NMSA 1978 or health insurer that involves", deleted former Paragraphs F(1) and F(2) and added new Paragraphs F(1) through F(8); in Subsection G, deleted "a person or a wholly or partially owned or controlled subsidiary of a person that provides claims administration, benefit design and management, pharmacy network management, negotiation and administration of product discounts, rebates and other benefits accruing to the pharmacy benefits manager or other prescription drug or device services to third parties, but ‘pharmacy benefits manager’ does not include licensed health care facilities, pharmacies, licensed health care professional, health insurers, unions, health maintenance organizations, medicare advantage plans or prescription drug plans when providing formulary services to their own patients, employees, members or beneficiaries;" and added "an entity that provides pharmacy benefits management services"; and deleted former Subsection H; and added new Subsections H and I and redesignated former Subsection I as Subsection J.