CurrentNew Mexico Health Care AuthorityPolicy N/A

Section 20: Pharmacy — Turquoise Care Pharmacy Benefits (Coverage Criteria)

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Rules and requirements for Managed Care Organizations (MCOs) administering Turquoise Care pharmacy benefits, including formulary/PDL, MAT, HCV, HIV, diabetic supplies, community pharmacy reimbursement, 340B billing, and related operational obligations.

Policy Summary

PayerNew Mexico Health Care Authority

PolicySection 20: Pharmacy — Turquoise Care Pharmacy Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionDo not require prior authorization for any Medication Assisted Treatment (MAT) medications; ensure all MAT drugs and forms are available without PA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No PA for MATMAT prior authorization prohibition

17+HCV treatment age threshold

120 daysAIR claim adjustment timeframe

1 per period

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Section 20: Pharmacy — Turquoise Care Pharmacy Benefits (Coverage Criteria)

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNew Mexico Health Care Authority

PolicySection 20: Pharmacy — Turquoise Care Pharmacy Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionDo not require prior authorization for any Medication Assisted Treatment (MAT) medications; ensure all MAT drugs and forms are available without PA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No PA for MATMAT prior authorization prohibition

17+HCV treatment age threshold

120 daysAIR claim adjustment timeframe

1 per period

PA limit for diabetes supplies

UD/08340B identification requirement

Coverage and Clinical Criteria

Chronic HCV Infection — Initial Treatment

MCOs are to approve properly requested treatments for Turquoise Care members with chronic HCV infection under the following conditions:

HCV treatment approval: Access to drug therapy without prior authorization or step therapy for glecaprevir/pibrentasvir (Mavyret®) or sofosbuvir/velpatasvir (Epclusa®); treatment for all HCV genotypes in members over age 17 with a positive Hepatitis C RNA level; other HCV medication requests must be appropriate per AASLD/IDSA guidance; plans may require resistance-associated substitutions testing based on AASLD guidance.age > 17; positive HCV RNA

Do not use active alcohol/drug use or provider specialty as screening criteria; quarterly data submission required.

Requests for off-label, experimental, or other treatments not specified in clinical guidelines must follow a documented escalation process before denial. The MCO shall initiate a peer-to-peer consultation with the requesting prescriber to review the clinical rationale and, if still considering denial, the MCO must present the case to Project ECHO prior to issuing a denial.

When a claim recoupment or payment reduction occurs more than seven calendar days after the original payment, the MCO must notify the provider of the reason and amount and must give the provider an opportunity to appeal or file a grievance; however, there is no fair hearing right for these recoupment/payment reduction notifications. If a pharmacy contract requires use of a PSAO, the PSAO must forward recoupment notices and any responses between the MCO and the pharmacy within three business days of receipt as specified.

MCOs must ensure PBMs and related contractors do not engage in prohibited conduct. Specifically, PBMs may not engage in spread pricing, charge unapproved fees related to claim adjudication, require inconsistent or additional accreditation beyond the Board of Pharmacy, or make untrue, deceptive, or misleading advertisements, promotions, solicitations, representations, proposals, or offers. MCOs are responsible for ongoing monitoring of PBM performance and compliance with these restrictions.

Hepatitis C treatment decisions must follow AASLD/IDSA guidance: access to glecaprevir/pibrentasvir (Mavyret®) and sofosbuvir/velpatasvir (Epclusa®) shall be provided without prior authorization or step therapy for eligible members. For Hepatitis C medications other than Mavyret® or Epclusa®, the MCO must ensure each request is appropriate per AASLD/IDSA guidance; plans may require resistance-associated substitution testing in accordance with AASLD recommendations.

Coding, Modifiers, and Billing Identifiers

340B and HCPCS/CMS Modifiersmixed

UD or 08	Modifier to identify 340B drug items (Medicaid Managed Care identification)
JW	Indicates waste (HCPCS modifier)
JZ	Indicates no waste (HCPCS modifier)
JG or TB	CMS modifiers for drugs acquired with 340B discount (accepted by Medicaid Managed Care)

Modifiers relevant to 340B and waste reportingModifier

UD	Modifier to identify 340B drug item (accepted by MCO)
08	Alternate modifier to identify 340B drug item
JW	Modifier indicates drug waste
JZ	Modifier indicates no drug waste
JG	Medicare modifier: drug/biological acquired with 340B discount
TB	Medicare modifier: drug/biological acquired with 340B discount (informational)

CMS unit typesmixed

EA	Each — drugs not identifiable by other unit type
CAP	Capsule
TAB	Tablet
GM	Grams
ML	Milliliter
AHF	Injectable Anti-Hemophilic Factor units
SUP	Suppository
TDP	Transdermal patch

HCV treatment age threshold — member age > 17 years

Age thresholdMembers older than 17 years are eligible for chronic HCV treatment

Required testPositive Hepatitis C RNA level within past two years (per outreach criteria)

Genotypes coveredAll HCV genotypes

Excluded screening criteriaActive alcohol/drug use and provider specialty must not be used to screen or deny treatment

Manufacturer expected sales threshold (units exceed expected sales / no record of sales)

Manufacturer dispute triggerManufacturers may dispute claims when billed units exceed the manufacturer's expected sales threshold for an NDC

Provider Responsibilities, Documentation & Billing Actions

Prior Authorization

No prior authorization for MAT; step‑therapy limits

Do not require prior authorization for any Medication Assisted Treatment (MAT) medications; MCOs shall not impose step therapy or prior authorization before authorizing coverage for FDA‑approved medications prescribed for autoimmune disorders, behavioral health conditions, cancer, or substance use disorders, except when a biosimilar, interchangeable biologic, or generic is available.

All MAT drugs and all formulations must be available without PA.
Generic-first may be required unless the prescriber writes 'brand medically necessary' on the prescription.

Documentation Required

Pharmacist enrollment and credentialing required

Enroll and credential pharmacist clinicians with New Mexico Medicaid Fee for Service and Managed Care Medical Plans before billing medical benefit claims for clinical services; MCOs must allow pharmacist credentialing consistent with other provider types.

Background and Scope

Medication Assisted Treatment (MAT) is the use of FDA‑approved medications combined with counseling and behavioral therapies to treat substance use disorders. For chronic Hepatitis C, oral direct‑acting antivirals are highly effective across genotypes; MCOs must establish systems to treat members over age 17 with active HCV infection, not use active alcohol or drug use or provider specialty as exclusionary screening criteria, and maintain outreach and screening plans aligned with USPSTF/CDC/AASLD/IDSA guidance.

Key Definitions

Medication Assisted Treatment (MAT) definition

DefinitionMedication Assisted Treatment (MAT) is the use of FDA‑approved medications, in combination with counseling and behavioral therapies, to provide a whole‑patient approach to the treatment of substance use disorders.

Included conditionsFDA‑approved medications exist to treat opioid use disorder, alcohol use disorder, and smoking cessation; MAT applies to these where indicated.

Medication accessMCOs must not require prior authorization for any FDA‑approved MAT drugs and must ensure all drugs, formulations, and delivery routes are available without unnecessary barriers.

340B drug definition / identification

Identification requirementAll pharmacy claims for items obtained under Section 340B must be identified on the billing transaction as 340B drug items using the 'UD' or '08' modifier.

Additional modifiers

Initial Therapy Coverage Criteria

HCV Initial Therapy — initial therapy coverage criteria

HCV initial therapy is covered when ALL of the following are met:

Initial HCV therapy: No prior authorization or step therapy required for glecaprevir/pibrentasvir (Mavyret®) or sofosbuvir/velpatasvir (Epclusa®).

Member eligibility: Member is older than 17 years of age and has a positive Hepatitis C RNA test result.age > 17; positive HCV RNA

Other agents: Requests for HCV medications other than Mavyret® or Epclusa® must be appropriate according to AASLD/IDSA guidance.

Plans may require resistance-associated substitutions testing per AASLD guidance.

Continuation and Grandfathering Criteria

Medication Grandfathering — continuation / stability criteria

Continuation of therapy (grandfathering) is allowed when the following condition is met:

Grandfathering: Recipients stabilized on a medication may continue without meeting MCO authorization criteria; when patient-specific criteria determine changing a drug is inadvisable, grandfathering must be granted for disease-specific parameters.stabilized on medication

No prior authorization required to continue current therapy.

Step Therapy Rules

Coverage requirement	Scope
MCO prohibition on step therapy prior to coverage of FDA‑approved medications	MCOs shall not impose step therapy or prior authorization before authorizing coverage for medications approved by the U.S. Food and Drug Administration when prescribed to treat an autoimmune disorder, a behavioral health condition, cancer, or a substance use disorder (unless a biosimilar, interchangeable biologic, or generic version is available).
Applicable products	All FDA‑approved medications for the listed conditions (autoimmune disorders, behavioral health conditions, cancer, substance use disorders); includes Medication Assisted Treatment (MAT) drugs which require no prior authorization.
Allowed exception	Step therapy or prior authorization may be imposed when a biosimilar, interchangeable biologic, or generic equivalent is available.

Quantity Limits and Prior Authorization Frequency

Diabetes supplies and drugs — prior authorization limit per policy period

PA frequency limitNo more than one prior authorization is allowed per policy period for any single diabetes drug or supply absent a change in diagnosis or management

Applies toBlood glucose monitors, test strips, lancets, insulin, syringes, injection aids, prescriptive oral agents, glucagon kits, and related diabetes supplies listed in policy

Exception for dose/quantity changesChanges in prescribed dose or quantities of supplies during the policy year already authorized are not subject to additional prior authorization in the same policy year if medically necessary

Site of Care Billing and Reimbursement Rules

Billing Rule

Outpatient I.H.S. and Tribal 638 pharmacies bill PBMs and follow AIR rules

I.H.S. and Tribal 638 outpatient pharmacies bill MCO PBMs for the pharmacy benefit and must be reimbursed per AIR rules; AIR reimbursement procedures apply to outpatient pharmacy drug claims.

MCOs must follow federal AIR reimbursement requirements and apply the published AIR rate.
Outpatient pharmacy drug claims under AIR follow the AIR reimbursement rules.

Billing Rule

Bill retail POS versus clinic billing per site of care

Medications dispensed or administered in retail/point‑of‑sale settings must be billed through normal POS procedures; medications administered in clinic settings must be billed pursuant to clinic billing procedures and administration fees are paid per contracted rates.

Policy Summary

PayerNew Mexico Health Care Authority

PolicySection 20: Pharmacy — Turquoise Care Pharmacy Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2024

Last ReviewJan 31, 2025

Next Review DateJan 31, 2025

Key ActionDo not require prior authorization for any Medication Assisted Treatment (MAT) medications; ensure all MAT drugs and forms are available without PA.

SourceLink

On This Page

No record of sales disputeManufacturers may dispute when there is no record of sales of the product within the state

MCO action on disputeMCO DRAMS contact must determine if provider used the NDC and obtain provider purchase documentation (e.g., wholesaler invoice) showing NDC and amount purchased

Pharmacists may bill via pharmacy POS or medical claims (CMS‑1500/UB‑04 accepted).
Clinical services must be documented to the same medical‑record standard as physicians/PA/NPs.

Note

MCO oversight of PBM compliance

Ensure contracted PBMs comply with the Pharmacy Benefits Manager Regulation Act (NMSA 1978 § 59A‑61) and monitor PBM performance and subcontractors to prevent prohibited practices such as spread pricing or deceptive representations.

Monitor PBMs to avoid spread pricing, deceptive advertising, or charging unapproved adjudication fees.
Follow Agreement requirements for oversight of major subcontractors and subcontractors.

Step Therapy

Step‑therapy and PA prohibition for specified FDA‑approved drugs

Do not impose step therapy or require prior authorization before authorizing coverage for FDA‑approved medications prescribed for autoimmune disorders, behavioral health conditions, cancer, or substance use disorders unless a biosimilar/interchangeable biologic or generic is available.

Grandfathering must be allowed for recipients stabilized on a medication; no PA required to continue current therapy.

Documentation Required

Provide medical‑record equivalent documentation and respond to manufacturer requests

Maintain clinical documentation and medical‑record equivalent notes for pharmacist clinical services and other disputed claims; be prepared to provide invoices or supporting records when the manufacturer or HCA's PBM requests documentation.

When a manufacturer requests documentation, HCA's PBM will notify the MCO, which is responsible for obtaining the documentation.
DRAMS comments will record how quantities were verified (e.g., call to provider).

Note

No step therapy‑specific requirements

No additional step‑therapy specific actions are required beyond the policy prohibitions; there are no separate step therapy requirements in the cited sections.

Documentation Required

Document 'brand medically necessary' for buprenorphine

When a prescriber indicates 'brand medically necessary' for buprenorphine used to treat opioid use disorder, the prescriber must document in the patient care notes that the patient failed generic therapy or did not maintain therapeutic response on the generic equivalent.

Pharmacy must bill using the 'dispense as written' indicator on the NCPDP claim when 'brand medically necessary' is written.
MCO must pay for the brand name when properly indicated.

Billing Rule

Retain MAC price selection and availability evidence

Retain documentation showing how MAC prices were selected and evidence that the chosen price source was available from wholesalers in New Mexico; if selecting the lowest available price, maintain proof that the source was available locally.

MAC payment levels must be reviewed at least weekly; price changes must be implemented within seven calendar days.
Short‑term or special deal prices may not be used to set the lowest MAC price.

Documentation Required

Document pharmacist clinical services to medical‑record standards

Document pharmacist clinical services to the same standard as physicians/PA/NPs and provide that documentation when requested to verify disputed units or quantities.

Do not substitute MTM billing codes when more applicable service codes are supported by clinical documentation.
Medical claims for pharmacist services may be billed electronically using clinical medical billing procedures.

Documentation Required

Obtain manufacturer‑requested documentation when notified

If the manufacturer requests additional documentation (for example an invoice), HCA's PBM will notify the MCO and the MCO is responsible for obtaining and submitting the requested documentation.

HCA's PBM will notify the manufacturer of dispute status and will enter DRAMS comments about verification steps.

Documentation Required

Ensure DRAMS entries and verification for unit disputes

HCA's PBM will enter DRAMS comments describing unit disputes and how quantities were verified; notify HCA's PBM of claim unit issues and provide verification details when requested.

MCOs must have providers adjust claims; DRAMS cannot change units on a claim.
If MCO verifies quantities are correct, notify HCA's PBM so DRAMS can record the verification.

Denial Risk

Confirm HCV requests meet AASLD/IDSA guidance

Ensure treatment requests for Hepatitis C medications other than Mavyret® or Epclusa® meet AASLD/IDSA guidance; inappropriate or insufficient requests may be denied.

Access to Mavyret® or Epclusa® requires no prior authorization or step therapy for eligible members.
Plans may require resistance associated substitutions testing based on AASLD guidance.

Billing Rule

Comply with AIR billing and reimbursement rules

Follow federal AIR billing requirements for I.H.S. and Tribal 638 outpatient pharmacy reimbursement; incorrect AIR billing or failure to follow AIR procedures can result in incorrect reimbursement or denial of AIR adjustments.

MCOs must reimburse the AIR published in the Federal Register and continue the prior year rate until the new rate is published.
It is the MCO's responsibility to monitor the Federal Register for AIR updates.

Denial Risk

Incorrect/terminated NDCs and quantity errors require provider correction

Claims with terminated/invalid NDCs, inaccurate NDCs, incorrect unit types, or inconsistent quantities can trigger manufacturer disputes; the provider must adjust and resubmit claims when the incorrect NDC or quantities were used.

MCO must contact the provider to determine the actual NDC used and require claim adjustment and resubmission (timely filing applies).
Notify HCA's PBM of incorrect units so DRAMS can document the dispute and coordinate manufacturer notification.

Denial Risk

Conditions allowing retroactive denials or reductions

A claim may only be retroactively denied or reduced after adjudication if the original claim was intentionally fraudulent, the original payment was incorrect because the provider was already paid, or the goods/services were not properly rendered.

CMS modifiers 'JG' or 'TB' (drug/biological acquired with 340B discount) shall be accepted by Medicaid Managed Care and may be used for informational reporting.

Related claim dataClaims must include manufacturer‑assigned NDC, a valid HCPCS or CPT code, a 'JW' (waste) or 'JZ' (no waste) modifier when applicable, and the unit of service.

Pharmacy POS billing for retail dispensed/administered medications.

Clinic‑administered medications billed under clinic billing procedures; vaccines administration fees per contract.