Current through Register Vol. 35, No. 18, September 24, 2024
A.
Dispensing frequencies: MAD limits the frequency for which it
reimburses the same pharmacy for dispensing the same drug to the same MAP
eligible recipient.
(1) The limitation is
established individually for each drug.
(2) Maintenance drugs are subject to a
maximum of three times in 90 days with a 14-calendar day grace period to allow
for necessary early refills.
(3)
Certain drugs are given more flexibility due to their specific dosage forms,
packaging or clinical concerns.
(4)
The excessive dispensing limitation applies regardless of whether the claim is
for a new prescription or refill.
(5) Schedule II controlled substances are
limited to a maximum 34-day supply. Initial use of controlled substances may
also be further limited by state law.
B.
Refill requirements: Refills
must be consistent with the dosage schedule prescribed and with all applicable
federal and state laws, regulations and rules. Consistent use of early refills
will result in a calculation that the MAP eligible recipient has sufficient
stock of the drug item on hand and allowed refill dates will be adjusted
accordingly.
C.
Quantities
dispensed: Maintenance drugs are those on the MAD-approved maintenance
drug list.
(1) For a MAP eligible recipient
with likely continuous eligibility due to age, disability or category of
eligibility, prescriptions for maintenance drugs may be dispensed in amounts up
to a 90-day supply.
(2)
Prescriptions for non-maintenance drugs are limited to 34-day
supplies.
(3) Oral contraceptives
may be dispensed for up to a one-year supply if the appropriate contraceptive
for the MAP eligible recipient has been established.
(4) Controlled substances may not be refilled
until 75 percent of the drug has been used based on the days supply of the
previous prescription unless the prescriber has been notified and given
approval. A pharmacy with access to dispensing information through a chain
store or linked database, or that is notified of early refills or other
dispensing of drugs through a point-of-sale system, is responsible for assuring
the refill meets the criteria by verifying the dispensing history available,
including the drug monitoring program database. Dispensed drug items which do
not meet these criteria are subject to recoupment.
(5) Pharmacy providers shall not reduce
prescriptions for maintenance drugs that are written for quantities larger than
a 34-day supply and may dispense up to a 90-day supply. MAD considers
prescription splitting to be fraudulent. Pharmacies that do not have the entire
prescribed amount on hand may dispense a partial fill.
(6) Coverage may be limited by the end date
of the MAP eligible recipient's span of eligibility at the time of
dispensing.
(7) Pharmacists are
encouraged to consult with prescribers to achieve optimal drug therapy
outcomes, consistent with NMSA 1978, Section 61-11-2(V).
(8) Controlled substances may have specific
controls on the quantities dispensed.
D.
Unit dose packaging: MAD does
not pay additional for unit dose packaging.
E.
Prevention of abuse: Drug
items are to be dispensed for legitimate medical needs only. If the pharmacist
suspects the MAP eligible recipient of over-utilizing or abusing drug services,
the pharmacist must contact the provider and MAD so that the MAP eligible
recipient's use of medications can be reviewed. Excessively high doses and
overlapping use of multiple drug items with the same therapeutic uses that are
potentially abusive or otherwise dangerous may result in subjecting the
prescriptions to the prior authorization process or recoupment from the
pharmacy if the prescriber is not contacted and the contact
documented.
F.
Mail service
pharmacy: MAD may provide a mail service pharmacy for a MAP eligible
recipient use.
(1) The mail service pharmacy
is available as an option to all MAP eligible recipients.
(2) Retail pharmacies may mail, ship or
deliver prescriptions to all MAP eligible recipients consistent with applicable
state and federal statutes, rules and regulations.
