Medication Assisted Treatment (MAT) Medications; Narcan and Naloxone
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
Directs Turquoise Care Managed Care Organizations to cease prior authorization for FDA‑approved MAT drugs, outlines generic‑first policy rules, and requires reimbursement for nasal Narcan and naloxone kits including counseling incentive fees; affects MCO coverage and pharmacy reimbursement for Medicaid members.
MCOs are directed to cease requiring prior authorization for any FDA‑approved MAT drugs, including methadone, buprenorphine, naltrexone, and combinations.
A generic‑first policy may be enforced unless prescriber writes 'brand medically necessary' by hand; in that case the MCO must pay for the brand and cannot require step therapy.
MCOs must reimburse pharmacies and providers for nasal Narcan and naloxone kits and pay the incentive fee for patient counseling and education when dispensed.
MAT and Naloxone Coverage Criteria
MAT and naloxone coverage criteria
Covered when the following directives and rules are met:
ALL of the following
ALL of the following
- No prior authorization is required for any MAT drug in any formulation when used to treat opioid use disorders.
Operational directive to MCOs to cease PA for MAT drugs.
ALL of the following
- Any formulation of buprenorphine used for the treatment of opioid use disorders is exempt from generic‑first coverage provisions.
- MCOs may require a generic version for other MAT drugs unless the prescriber handwrites 'brand medically necessary' on the prescription.
ALL of the following
- When the prescriber handwrites 'brand medically necessary' on the prescription (not a rubber stamp), the pharmacy must bill using the NCPDP 'dispense as written' indicator.
- If 'brand medically necessary' is handwritten, the MCO must reimburse the brand product and may not impose step therapy.
ALL of the following
- MCOs must reimburse pharmacies and other providers for nasal Narcan and for naloxone kits whenever dispensed.
- MCOs must pay the incentive fee for patient counseling and education when nasal Narcan or a naloxone kit is dispensed.
ALL of the following
- Best clinical practices for buprenorphine prescribing (e.g., PDMP checks, periodic urine drug screening) should be implemented via provider alerts rather than enforced through prior authorization processes.
Billing and NCPDP Code Guidance
| NCPDP dispense as written indicator | Billing indicator used when prescriber writes 'brand medically necessary' on prescription |
Provider and MCO Operational Actions
Stop requiring prior authorization for all FDA‑approved MAT drugs
MCOs are directed to cease requiring prior authorization for any FDA‑approved MAT drugs, including methadone, buprenorphine, naltrexone, and buprenorphine/naloxone combinations; no prior authorization is required for any MAT drug formulation when used to treat opioid use disorders.
Handle 'brand medically necessary' with NCPDP dispense‑as‑written and reimburse brand
If the prescriber handwrites 'brand medically necessary' on the prescription (not a rubber stamp), the pharmacy must bill using the NCPDP 'dispense as written' indicator and the MCO must reimburse the brand; in that situation no step therapy may be required.
- Handwritten 'brand medically necessary' is required (stamps do not qualify).
- Pharmacy uses the NCPDP 'dispense as written' billing indicator.
- MCO must pay for the brand and cannot impose step therapy when this indicator is used.
Do not enforce clinical monitoring via prior authorization; use provider alerts
Best clinical practices for MAT (for example, systematic PDMP checks and periodic urine drug screening) should be implemented via provider alerts and not enforced through prior authorization requirements.
- Clinical monitoring (PDMP checks, urine drug screening) is a provider alert matter, not a PA condition.
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.