New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 30 - PHARMACY BENEFITS MANAGERS
Section 13.10.30.7 - DEFINITIONS
Current through Register Vol. 35, No. 6, March 26, 2024
For purposes of this rule and the Pharmacy Benefits Manager Regulation Act:
A. "Clean claim" has the definition found in Paragraph (1) of Subsection A of Section 59A-16-21.1 NMSA 1978.
B. "Client" means any person with whom a PBM contracts to provide pharmacy benefits management services arising out of or relating to pharmacy operations in New Mexico.
C. "Formulary" is a list of prescription drugs that has been developed by a health insurance carrier or its designee that the carrier or health plan in determining applicable prescription drug coverage and benefit levels.
D. "Health insurance carrier" or "carrier" has the definition found in Paragraph (2) of Subsection C of Section 59A-16-21.2 NMSA 1978.
E. "Health plan" has the definition found in Paragraph (3) of Subsection A of Section 59A-16-21.1 NMSA 1978.
F. "NCPDP" means the national council for prescription drug program.
G. "NDC" means national drug code.
H. "Network pharmacy" means a pharmacy with whom a payor or PBM has contracted to provide pharmacy services to persons with an expectation of receiving payment directly or indirectly from the carrier.
I. "Prescription drug claim administration" is administrative services performed in connection with the processing, adjudicating and auditing of claims relating to pharmacy services.
J. "Similarly situated" refers to a network pharmacy whose PBM contract is subject to the same reimbursement for a claim as a pharmacy whose appeal was granted.
